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2. First Name
3. Last Name
5. Street Address
7. Phone Number
8. Email Address
10. Are you a registered voter and a resident of the City of Columbus, MS?
11. Select One

    1. Yes
    2. No
13. Board position you are applying for (Select One)
    -- Select One --Civil Service CommissionConvention & Visitors BureauCity Utilities CommissionColumbus Municipal School DistrictColumbus Housing AuthorityMunicipal Election CommissionColumbus-Lowndes Library BoardZoning Board of Adjustment & AppealsBoard of Adjustment & Appeals of Development CodesHistoric Preservation CommissionCity Planning CommissionGolden Triangle Regional Waste Management AuthorityTree BoardGolden Triangle Airport BoardRedevelopment Authority BoardGolden Triangle Link Development BoardColumbus Lowndes Airport Board
15. If Board you are applying for has employees, please read and sign the following:

    Please answer whether you have any family members working for the unit of government in which you are applying for a board appointment:

    1. Yes
    2. No
17. If yes to above question, what relation?
19. If the answer to the foregoing question was “Yes”, please understand that if you are selected for the board appointment, if the family member does not resign before you take office, you may violate the Ethics in Government laws (Mississippi Code Section 25-4-101 et seq.), Section 109 of the Mississippi Constitution or Mississippi’s anti-Nepotism Laws (Mississippi Code Section 25-1-53). If there is a violation of one or more of these laws, by accepting appointment, you could be personally liable to repay compensation paid to a family member from the time of your taking office going forward and may be fined or penalized. If the answer is yes, you are advised to seek legal advice on the consequences of acceptance of the Board appointment.

    1. Yes, I have read and understand the above and foregoing paragraph:
21. Please tell us why you would like to serve on this board.
23. Educational Background
25. Professional Experience
27. Other Experience
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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