Form Center

2. First Name
3. Last Name
4. Address
6. City
7. State
8. Zip
9. Are you a resident of Lake Jackson*

   1. Yes
   2. No
11. Day Time Phone #:
12. Cell Phone #:
13. Email address that can be used for communication of meetings between city staff and board members:
15. Do you give consent to publish your email address on various city media outlets?

    1. Yes
    2. No
16. How long have you lived in Lake Jackson:
    Number of years
17. Are you a registered voter?

    1. Yes
    2. No
18. Education

    1. High School
    2. College Degree
    3. Bachelor's Degree
    4. Master's Degree
    5. Doctorate

    Select all that apply
20. Place of Employment:
21. Occupation:
22. List any experience, education, community activities or other information you believe should be considered for your appointment to this board or commission:
24. Please choose from the dropdown menus listed below which boards and/or commissions you are interested in serving on. Please choose 3 boards below that interest you the most:
26. 1st Choice
    -- Select One --BlankPlanning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizen CommissionCharter Review CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CorpBoard of HealthDangerous Structure Determination Board
27. 2nd Choice
    -- Select One --BlankPlanning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizen CommissionCharter Review CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CorporationBoard of HealthDangerous Structure Determination Board
28. 3rd Choice
    -- Select One --BlankPlanning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizen CommissionCharter Review CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CorporationBoard of HealthDangerous Structure Determination Board
30. Misc. Information you would like to provide:
31. By selecting the accept button below you are acknowledging that the information submitted on this form is considered to be public information. *

    1. Accept
    2. Do Not Accept
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field