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Survey/Form Review
Board and Commission Applicant Information Sheet
1. It is the policy of the City of Brentwood that family members living in the same household or other individuals living in the same household may not concurrently serve on City boards.*
2. Please select the Board you wish to apply for:*
3. What is your name?

4. Spouse's name (if applicable)?

5. Address:

6. Home Phone:

7. Business Phone:

8. Fax Number:

9. Email address:

10. Employer

11. Occupation:

12. Spouse Employer:

13. Spouse Occupation:

14. How long have you lived in Brentwood:

15. Community Involvement:

16. Brief summary of why you would like to serve on this board:

The following questions request additional information that may be pertinent in the consideration of appointments to City boards. Affirmative responses to these questions will not necessarily be grounds for disqualification, but provide the opportunity for you to identify relationships or potential conflicts that should be disclosed prior to an appointment being made.
17. Are you related by blood, marriage or adoption to any member of the Brentwood City Commission, any employee of the City of Brentwood, or any member of a City of Brentwood volunteer board? If so, please describe:

18. Do you or any member of your immediate family, your employer or any association/community group with which you are affiliated have a business relationship with the City of Brentwood, or has there been such a relationship with the City in the past? If so, please describe:

19. If appointed to the board identified above, are you aware of any potential conflicts of interest you may have in regard to business before the board? If so, please describe:

20. By submitting this application, I confirm that the above information is true and correct and, if I am appointed to a board, I affirm that I will regularly attend the board’s meetings and functions.*
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