Forms • Shelby County, TN • CivicEngage

Boards and Commissions Application

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BOARD/COMMISSION INTERESTED IN: *
Name*
Date of Birth*
Race*
Sex*
Business Name*
Business Address*
City, State, Zip
E-mail address*
Business Phone
Education*
Name of Spouse
Home Address*
City*
State*
Zip Code*
Phone*
How many years have you been a resident of Shelby County?*
Have you ever been convicted of a felony?*
Do you give Shelby County Government authorization to request that the Shelby County Sheriff's Department perform a background check?*
Do you also understand that other sources including the official state websites listing sexual predators and a check of outstanding balances owed to departments and offices of county government may be performed?*
List any affiliation or ownership interest you have in any business, corporation or partnership and if such business contracts with or sells products or services to Shelby County Government.*
List members of family, where employed, and whether or not their employer contracts with or sells products or services to Shelby County Government.*
Signature*
Date*
Pursuant to Resolution #26 adopted July 26, 1993, as amended, each person who submits his or her name for nomination to serve on a board, authority, or commission subject to approval by the Shelby County Board of Commissioners shall submit a list of all private, county, social, athletic or professional clubs of which that person is a member. In the event it is determined that any such clubs are discriminatory in choosing their members on the basis of race, sex, or religion, the Shelby County Board of Commissioners may use this information in voting to reject the nominee.
Pursuant to the aforementioned Resolution you are hereby required to list all private country, social, athletic or professional clubs of which you belong.*
List below any of the aforementioned clubs of which you belong that do not have female members.*
List below any of the aforementioned clubs of which you belong that do not have minority group members (e.g. African American, Hispanic, Asian).*
Do any of the aforementioned clubs of which you belong discriminate in selecting members based on race, sex, or religion?*
Submitted by*
Signature*
Date*

* indicates required fields.

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