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2. Please choose which board / committee you would like to apply for:*
   -- Select One --Beautification and Arts Advisory Committee (Meets Bi-Annually)Beer Board (Meets Monthly)Board of Zoning Appeals (Meets Monthly)Construction Board of Adjustment and Appeals (Meets As Needed)La Vergne Housing Authority (Meets Monthly - Not a City Board)La Vergne Industrial Development Board (Meets As Needed)Library Board (Meets Bi-Monthly)Parks & Recreation Advisory Committee (Meets Bi-Monthly)Planning Commission (Meets Monthly)Stormwater Appeals and Advisory Board (Meets Bi-Annually)Other
3. Other*

   Please specify.

5. If you are appointed, will you have any potential conflicts of interest?*

   1. Yes
   2. No
6. If yes, please explain.*
10. Applicant Information
11. First Name*
12. Last Name*
14. Email Address*
15. Phone Number*
17. Address*
19. City*
20. State*
21. Zip Code*
23. What is the best time to contact you?*

    Select at least one.

    1. Morning (8:00 a.m. - Noon)
    2. Afternoon (Noon - 4:30 p.m.)
24. What is the best way to contact you?*

    Select at least one.

    1. Mail
    2. Cell Phone
    3. Email
28. Education

    Leave sections blank that are not applicable.

30. High School
31. College University
32. Graduate / Professional
34. School Name
35. School Name
36. School Name
38. City, State
39. City, State
40. City, State
42. Years Completed

    N/A

43. Years Completed

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5+
44. Years Completed

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5+
46. Course of Study

    N/A

47. Course of Study
48. Course of Study
50. Diploma Received

    1. Yes
    2. No
51. Diploma Received

    1. Yes
    2. No
52. Diploma Received

    1. Yes
    2. No
54. Any additional information regarding education:
58. Experience
59. Current Occupation*

    Please include Title and Organization name, separated by a comma

61. List any experience that would apply to the Board or Committee you are applying for.*
62. Please attach your most up to date resume.
64. List any municipal boards / committees on which you currently serve.
66. Board / Committee #1
67. Year Appointed
69. Board / Committee #2
70. Year Appointed
72. Board / Committee #3
73. Year Appointed
75. Additional Entries

    Separate board or committee and year appointed by a comma. Begin a new line for each entry.

77. List any municipal boards / committees on which you have previously served.
79. Board / Committee #1
80. Years Active
82. Board / Committee #2
83. Years Active
85. Board / Committee #3
86. Years Active
88. Additional Entries

    Separate board or committee and years active by a comma. Begin a new line for each entry.

92. References

    List three (3) professional or business references.

94. 1. Name*
95. Email Address*
96. Phone Number*
97. Years Known*
99. 2. Name*
100. Email Address*
101. Phone Number*
102. Years Known*
104. 3. Name*
105. Email Address*
106. Phone Number*
107. Years Known*
111. Application Acknowledgement and Agreement*

     I hereby affirm that the information provided on this application (and accompanying documents, if any) is true and complete to the best of my knowledge. I understand that falsified information or significant omissions may disqualify me and my application from further consideration for a Board or Committee member appointment and may be considered justification for removal from a Board or Committee, if discovered at a later date. 

     I waive any right of privilege, privacy, and/or confidentiality I may have in the information provided by references or others whom I have indicated may be contacted. 

     I hereby understand and acknowledge that, unless otherwise defined by applicable law, any relationship with this organization is of an “at will” nature, which means that the Board or Committee member may resign at any time and the Board of Mayor and Aldermen may remove the Board or Committee member at any time with or without cause. I understand, also, that I am required to abide by the Charter and Ordinances of the City of La Vergne, the Constitution and Laws of the State of Tennessee and the Constitution and Laws of the United States of America.

     1. I agree.
113. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree
115. Electronic Signature*
116. Today's Date*
     Today's Date
118. Thank you for your willingness to serve.
Leave This Blank:


120. 1. Receive an email copy of this form.
121. Email address

     This field is not part of the form submission.

122. Submit

* indicates a required field