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2. Prefix
4. First Name*
5. Last Name*
7. Suffix
9. Street Address*
11. City
12. State
13. Zip
15. Email Address*
    Please use your personal email address
17. Employer*
18. Occupation*
20. Primary Phone*
21. Alternate Phone
23. Upload your resume*

    Please include in your resume:

    • Name and contact information
    • Educational History
    • Professional Experience
    • Volunteer Experience
    • Months per year of residency in Moline, IL.

    
    

27. Which Boards/Commissions would you like to apply for?*

    1. Citizen's Advisory Council on Urban Policy (CACUP)
    2. Fire & Police Commissioners
    3. Fire Pension Board
    4. Historic Preservation Commission
    5. Human Rights Commission
    6. Keep Moline Beautiful Commission
    7. Library Board of Trustees
    8. Moline Centre Main Street Commission

    1. Moline Housing Authority
    2. Park Board
    3. Plan Commission
    4. Police Pension Board
    5. Project Management Team
    6. Revolving Loan Fund Committee
    7. Youth Commission
29. Do you or a member of your immediate family have ownership interest in any company that does business with the City of Moline? *

    1. Yes

    1. No
31. Do you or a member of your immediate family have ownership interest in any property that is the subject of a condemnation proceeding, planning and zoning proceeding or any other administrative or court proceeding in which the City of Moline is an interested party?*

    1. Yes

    1. No
33. Do you have any contract or matter pending with the City of Moline? *

    1. Yes

    1. No
35. Do you hold any elected or appointed office for any unit of government?*

    1. Yes

    1. No
37. If so, please list
39. Do you serve in any capacity in which you are appointed by the Governor? *

    1. Yes

    1. No
41. If so, please explain
43. Have you served on a Moline board or commission in the past? *

    1. Yes

    1. No
45. If so, please provide the name of the Board or Commission
47. Additional Notes
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field