Application for Appointment Form

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City of Moorhead Committee/Board/Commission
Please correct the field(s) marked in red below:

Questions with an * are required, others are not.
Full Name
 *
Home Address
 *
Ward
 *
Day Phone
 *
Evening Phone
Personal Email Address
 *
Employer
 *
Occupation
 *
Work Address
 *
Work Phone
 *
May we contact you at work?
 *
If yes, what are your work hours?
Work Email Address
Please indicate the City of Moorhead Commitee/Board/Commission on which you would like to server (choose your top 3):
 *

OPTIONAL:

The City strives to have a variety of people serving on its committees/boards/commissions. The following information is optional, but would be helpful to us in achieving our goal of balance.

Gender
Age
Racial/Ethnic Group

How long have you been a Moorhead resident?
 *
Please describe why you are interested in being appointed.
 *
Provide a brief description of your background and experience relevant to appointment.
 *

Do you have any special qualifications that you feel would help you be particularly effective

(i.e. work experience, volunteer experience, education, professional or organizational memberships, hobbies, etc.)?

 *
What are your ideas or observations on the role of this Committee/Board/Commission?
 *

CONSENT TO RELEASE PRIVATE DATA

Below you will find a copy of the Minnesota State Statute that explains what data furnished by you are considered public and private. By completing the information below you will authorize the City of Moorhead to release the following private data upon request. Please check all that may be made public.

You must choose at least one phone number or e-mail address to be made public.
 *

MINNESOTA STATUTES 201

13.601 ELECTED AND APPOINTED OFFICIALS

Applicants for appointment

(a) Data about applicants for appointment to a public body collected by a government entity as a result of the applicant's application for appointment to the public body are private data on individuals except that the following are public:

(1) name;
(2) city of residence, except when the appointment has a residency requirement that requires the entire address to be public;
(3) education and training;
(4) employment history;
(5) volunteer work; (6) awards and honors; (7) prior government service; (8) any data required to be provided or that are voluntarily provided in an application for appointment to a multimember agency pursuant to section 15.0597; and
(9) veteran status.

(b) Once an individual is appointed to a public body, the following additional items of data are public:

(1) residential address;
(2) either a telephone number or electronic mail address where the appointee can be reached, or both at the request of the appointee;
(3) first and last dates of service on the public body;
(4) the existence and status of any complaints or charges against an appointee; and
(5) upon completion of an investigation of a complaint or charge against an appointee, the final investigative report is public, unless access to the data would jeopardize an active investigation.

(c) Notwithstanding paragraph (b), any electronic mail address or telephone number provided by a public body for use by an appointee shall be public. An appointee may use an electronic mail address or telephone number provided by the public body as the designated electronic mail address or telephone number at which the appointee can be reached.

 Applications will be kept on file for two (2) years after date of submittal.

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