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2. Description

   Montgomery County encourages all residents to consider serving on one of our boards or commissions. Please complete this application to indicate your interest to serve. After your application is received, we will reach out to confirm your information and interest. Once a board vacancy is available, we will consider your application for appointment. To see a full list of boards and commissions, visit www.montcopa.org/boards.

   The County will use the demographic information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. Your responses will not be disclosed in identifiable form without your informed consent. 

   Please note that individuals with expiring terms may also be reappointed.

4. First Name*
5. Last Name*
7. Home Address 1*
9. Home Address 2
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. Employment: Company or Business Name
20. Work Address 1
22. Work Address 2
24. Work Phone Number
25. Work Email
27. Preferred Method of Contact
    -- Select One --Personal Phone NumberPersonal EmailWork PhoneWork Email
28. Best Time To Be Contacted
30. Gender (Check all that apply)

    1. Female
    2. Male
    3. Non-binary, transgender, or another gender
    4. Prefer not to answer
31. If your identity is not listed, please use this box to describe it.
33. Race/Ethnicity
    -- Select One --Latino/HispanicWhite alone, non-Latino/HispanicBlack or African American alone, non-Latino/HispanicAmerican Indian and Alaska Native alone, non-Latino/HispanicAsian alone, non-Latino/HispanicNative Hawaiian and Other Pacific Islander alone, non-Latino/HispanicMultiracial, non-Latino/Hispanic
34. Do you self-identify with any of the following communities?

    1. Person with a disability
    2. Veteran
    3. LGBTQIA+
36. Age Range
    -- Select One --18 - 29 years old30 - 45 years old46 - 55 years oldOver 55 years old
37. Please attach your resume or bio here. If you don't have either of these, you may use the space below to summarize your relevant experience.
39. If you don't have a resume, please provide a brief statement about work you have done relevant to the board for which you are applying.*
41. Which program office Board are you interested in joining? (Check all that apply.)

    1. Advisory Council to Senior Services
    2. Agricultural Land Preservation Board
    3. Board of Assessment Appeals
    4. Board of Health
    5. Board of Managers of the Youth Center
    6. Board of Prison Inspectors
    7. Board of Trustees of the Community College
    8. Citizens Advisory Committee
    9. Conservation District
    10. Criminal Justice Advisory Board
    11. Delaware Valley Regional Finance Authority
    12. Delaware Valley Regional Planning Commission
    13. Drug & Alcohol Planning Council
    14. Emergency Dispatch Radio Committee
    15. Emergency Services Advisory Committee
    16. Family Justice Advisory Board
    17. Fire Advisory Committee
    18. Housing Authority
    19. Industrial Development Authority
    20. Local Emergency Planning Committee
    21. Mental Health and Developmental Disabilities
    22. Mill Grove Board
    23. Montgomery County Transportation Authority
    24. Montgomery County-Norristown Public Library Board
    25. Open Space Board
    26. Parks, Trails & Historic Sites Advisory Board
    27. Planning Commission Board
    28. Public Defender Advisory Board
    29. Redevelopment Authority
    30. SEPTA Board
    31. SEPTA Citizens Advisory Board
    32. Suburban Transit Network Inc.
    33. Valley Forge Tourism and Convention Board
    34. Workforce Development Board (MontcoWorks)
    35. Youth Committee
43. In a few sentences, please briefly why you are interested in joining the Board(s) that you selected. Please indicate how you feel you will represent the Board and bring a unique/diverse perspective.
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

* indicates a required field