Form

Citizens’ Bond Oversight Committee Application Form

QUALIFICATION STANDARD: To be a qualified person to serve on a committee you must be at least 18 years of age and reside within the District’s geographic boundary, in accordance with Government Code Section 1020.

Geographic Boundaries: Alameda, Albany, Berkeley, Emeryville, Oakland, or Piedmont

GENERAL INFORMATION:

First name*

Last name*

Phone Number*

Street Address*

City*

State/Region*

Email*

EMPLOYMENT INFORMATION

Name of Employer*

Occupation*

Work Address*

Work Phone*

COMMITTEE INTEREST:

Please specify which position(s) you are qualified/applying for and identify any organization in which you are an active participant:

Active in a business organization representing the business community located in the District

Active in a senior citizens’ organization

Active member of a bona fide taxpayer organization

District student and active in a community college group, such as student government

Active member in the support and organization of a community college or the community colleges of the District, such as a member of an advisory council or foundation

At-large community member

Organization

Additional Information:

Have you been a member of any community college or school district or school-based committee?*

Yes

If so, which one, and in what capacity?

Are you an employee of the Peralta Community College District? (NOTE: Employees of the District are prohibited from being members of the Committee.)*

Yes

Have you ever been employed by the Peralta Community College District?*

Yes

Are you a vendor, contractor, or consultant to the Peralta Community College District? (NOTE: Vendors, contractors, and consultants of the District are prohibited from being members of the Committee.)*

Yes

Are you able to complete at least one term (two years) as a member of a Committee and refrain from becoming an employee, vendor, contractor, or consultant of the Peralta Community College District during such time?*

Yes

List present or past membership in any community service, civic, or other pertinent organization. Please also list participation in seminars, workshops, volunteer work, professional organizations, etc.

Please answer the following questions:

Are you currently a resident within the Peralta District?*

Yes

If yes, what city?

Do you have any children or grandchildren who now attend (or have attended) Peralta Community College District?*

Yes

Do you know of any reason, such as a potential conflict of interest, which would adversely affect your ability to serve on a Committee?*

Yes

List references that have knowledge of your character, experience, and abilities. Do not include names of relatives. (You may attach letters of reference from those listed if you wish.). Please provide Name/Address/Phone/Business/Occupation for each reference: *

Explain why you would like to be appointed to a Committee.*

CERTIFICATE OF APPLICANT:

All answers and statements in this document are true and complete to the best of my knowledge and belief.

Signature*

Date*

Month/Day/Year