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11/04 <br /> APPLICATION FOR HAWAII COUNTY BOARDS AND COMMISSIONS <br /> Our goal, in addition to meeting State and County regulations regarding the composition of a particular board or <br /> commission, is to select members who bring a variety of skills and life experiences to these agencies. The answers to the <br /> following questions can assist us in these efforts. <br /> NAME DATE <br /> Last First Middle <br /> RESIDENCE ADDRESS <br /> City State Zip <br /> MAILING ADDRESS <br /> City State Zip <br /> PHONE <br /> Home Business Cell Fax <br /> U.S. CITIZEN ❑Yes ❑ No HAWAII COUNTY VOTER ❑ Yes ❑ No COUNCIL DISTRICT <br /> (Call 961-8277 if not sure) <br /> DATE OF SOCIAL LENGTH OF RESIDENCE <br /> BIRTH SECURITY NO. IN HAWAII <br /> MARRIED ❑Yes ❑ No NAME OF SPOUSE <br /> EDUCATION <br /> EMPLOYMENT RECORD (Past ten years) <br /> FROM (Year) TO (Year) EMPLOYER OCCUPATION <br /> Are you currently serving on any federal, state or county board or commission? ❑Yes ❑ No <br /> If yes, name the entity and date your term ends: <br /> List by preference the board or commission you wish to serve on: <br /> 1. 3. <br /> 2. 4. <br /> Briefly explain your interest in being a member of a particular board or commission. <br /> Are you currently an official and/or card carrying member of any of the following political parties? <br /> ❑ Democrat ❑ Republican ❑ Green ❑ Libertarian ❑ None <br />