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Boards and Commissions Application Form

2. Applicant Information

4. First Name*

5. Last Name*

7. Address*

8. City*

9. State*

10. Zip Code*

12. Home / Cell Phone*

13. Email Address*

14. Length of Bentonville Residency*

16. Employer*

17. Occupation*

18. Business Phone*

22. References
    Please provide 2 references

    Please provide 2 references

24. Name

25. Email Address

27. Address

29. City

30. State

31. Zip Code

33. Phone Number

35. Name

36. Email Address

38. Address

40. City

41. State

42. Zip Code

44. Phone Number

45. Fax Number

49. Board Selection and Qualifications

51. Select all commissions and boards for which you would like to be considered:*

    1. Advertising & Promotion Commission
    2. Bentonville Municipal Airport Advisory Board
    3. Board of Adjustment
    4. Diversity, Equity and Inclusion ((DEI) Community Task Force
    5. Library Advisory Board
    6. NACA Board
    7. NWA International Airport Authority Board of Directors

    1. Ozark Regional Transit Authority
    2. Parks and Recreation Advisory Board
    3. Planning Commission
    4. Public Art Advisory Committee
    5. Tree & Landscape Advisory Committee
    6. Utility Board

53. 1. What are your qualifications for serving on this commission or board, including education and subject matter expertise?*

55. 2. Why would you like to be considered for appointment to this commission or board?*

57. 3. What do you hope to be able to contribute?*

61. Qualifications for Serving
    Please read the Qualifications for Serving provided below. These are the general qualifications to serve on any board or commission of the City of Bentonville.

    Please read the Qualifications for Serving provided below. These are the general qualifications to serve on any board or commission of the City of Bentonville.

63. 

65. I have read the above qualifications to serve on a city commission or board.*

    1. Yes
    2. No

69. Restrictions on Appointees
    Please read the Restrictions on Appointees provided below. Then type in your name and date to confirm that you are aware of and, if appointed, agree to the following rules.

    Please read the Restrictions on Appointees provided below. Then type in your name and date to confirm that you are aware of and, if appointed, agree to the following rules.

71. 

73. Agreement to Abide by Restrictions on Appointees*

    By typing in your name above, you confirm your awareness and agreement to follow the above listed restrictions on appointees.

74. Date*
    Date

Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit Submit and Print

* indicates a required field