2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Home Phone
12. Work Phone
13. Cell Phone
15. I seek appointment as a nonelected member of the Board of Health in the category below:

    1. Consumer of Public Health
17. I am applying to serve on:
    -- Select One --Jefferson County Board of Health
18. I reside in Commissioner District Number:
    -- Select One --#1#2#3
20. Explain how and why you satisfy the requirements of the category, providing as many specific examples as you think would be helpful to the Board in considering your application. Please feel free to submit additional materials if you that will also be helpful.
22. What community activities have you participated in during the past five years?
24. Please describe how in the past you have demonstrated a commitment to or passion for public health.
26. Please share why you are you applying for this appointment?
28. Please share and describe how and why your appointment to the Board would advance the the goal of increasing the diversity of expertise and lived experience on the Board.
30. In addition to those already described, please tell uswhat other special skills, knowledge, or experience do you have that would contribute to the Board and its commitment to public health.
32. Please tell us whether you identify with a historically underrepresented community, describing the community, and how your identification with this community would positively contribute to the Board.
34. What limitations, if any, are there on the time you would be available for meetings and other activities? How much time are you able to devote to the duties of this Board.
36. Please share any additional information you would like to provide about yourself:
38. Please upload any additional files for your application.
40. By typing my name below, I understand that this appointment will entail my attendance at meetings and participation in activities of this Task Force. All of the information on this application is true to the best of my knowledge.
42. First Name
43. Last Name
44. Date
    Date

    Date
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field