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2. First Name*
3. Last Name*
5. Email Address*
7. Home Mailing Address*
9. Home Physical Address*
11. City*
12. State*
13. Zip Code*
15. County of Residence*
16. Primary Phone*
18. Education*
20. Employment History
22. Business Name*
23. Business Position*
24. Business Address*
26. Business Phone*
27. Dates of Employment?*
29. Training, experience or qualifications related to board/committee to which appointment is sought:*
31. State reasons you are interested in appointment which is sought:*
33. Do you currently serve on an Allegany County Board/Committee?*

    1. Yes
    2. No
35. Have you served on an Allegany County Board/Commission in the past?*

    1. Yes
    2. No
37. Do you currently work for an entity or agency that either receives funding from or has a contract with the County to perform services?*

    1. Yes
    2. No
39. Are you, your spouse or children, currently an officer, director, or partner in any entity or agency that receives funding from, or has a contract with the County?*

    1. Yes
    2. No
41. Please check Board(s)/Committee(s) that interest you.

    1. Adult Public Guardianship Review Board
    2. Agricultural Land Preservation Advisory Board
    3. Allegany County Police Accountability Board
    4. Allegany County Administrative Charging Committee
    5. Animal Control Advisory Board
    6. Airport Authority (Potomac Highlands Airport)
    7. Building Code Appeals Board
    8. Appeals Panel for Classified Service
    9. Del Commission
    10. Drug and Alcohol Abuse Advisory Council
    11. Board of Elections
    12. Region 1 EMS Advisory Council
    13. Emergency Services Board
    14. Enterprise Zone Advisory Committee
    15. Ethics Commission
    16. Gaming Hearing Officers
    17. HRDC Board

    1. LaVale Sanitary Commission
    2. Library Board of Trustees
    3. Liquor Board
    4. Local Development Council
    5. Mental Health Advisory Board
    6. Upper Potomac River Commission
    7. Planning Commission
    8. Property Tax Assessment Appeals Board for Allegany County
    9. Housing Authority of Allegany County
    10. Salary Study Commission
    11. Sanitary Commission, Allegany County
    12. Social Services
    13. Solid Waste Management Board
    14. Tri-County Council for Western Maryland
    15. U. S. Constitution Monument Committee
    16. Zoning Appeals
    17. Commission for Women
43. I will attend meetings in accordance with the adopted policies of Allegany County. If at any time my business or professional interests conflict with the interests of this Board or committee, I will not participate in such deliberations. References may be secured from the following individuals: (Include Name, Address, Phone)
45. Name*
46. Address*
47. Phone*
49. Name*
50. Address*
51. Phone*
53. Name*
54. Address*
55. Phone*
57. Please upload any supporting documents for consideration. (Optional)
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

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