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2. The information provided on this form is for the use of the Upson County Board of Commissioners in its deliberation to fill vacancies on committees, boards, and commissions. Applications may be submitted at any time and will be kept on file for a period of one year. Applicants may be asked to attend a designated meeting of the County Board of Commissioners for application review and appointment consideration.

4. To which committee, board or commission are you seeking appointment?*
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. ZIP Code*
15. County Commission District*
17. Date Available for Appointment*
    Date Available for Appointment
19. Are you a registered voter in Upson County?*

    1. Yes
    2. No
21. If "Yes", which township, city, or village?*
23. Is the township, city, or village incorporated or unincorporated?*

    1. Incorporated

    1. Unincorporated

27. Please complete the following.

29. Community Service*

    List boards, commissions, committees or community service organizations that you are currently serving or have served upon, offices held, and in what municipality or county.

31. Employment & Education*

    List any employment experience or education that, in your opinion, best qualifies you for this appointment. List job titles, duties (current and past), level of education and certificates or degrees you have obtained.

33. Have you ever worked for Upson County?*

    1. Yes
    2. No
35. If "Yes", please list dates and name(s) of departments.*
37. Rules of law and ethics prohibit appointees from participating in and voting on matters in which they may have a direct or indirect financial interest. Are you aware of any potential conflicts of interest?*

    1. Yes
    2. No
39. If "Yes", please indicate potential conflicts.*
41. Are you aware of time commitment necessary to serve on the committee, board, and/or commission to which you seek appointment and will you have such time?*

    1. Yes
    2. No
43. Please provide information about specific training, education, experience or interests you possess that qualify you as an appointee to the position you seek.*

47. I hereby certify that the preceding information is correct and to the best of my knowledge.

49. Electronic Signature*
50. Date*
    Date

52. Thank you very much for giving us the opportunity to consider you for appointment.

Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field