CTUIR - Committee and Commission Application

First and Last Name *

Enrollment Number *

Telephone Number *

Email Address *

Street Address *

Apt/Space/Suite etc

City *

State *

Zip Code *

Is Your Mailing Address Different from Your Physical Address *

Yes
No

Street/PO Box

Apt/Space/Suite etc

City

State

Zip Code

Job title, program/department

Supervisor Name

Supervisor Email

10. Does your current work schedule (if applicable) conflict with the meeting time of the Committee/Commission for which you are applying? *

Yes
No

11. Do you have any immediate relatives employed in the department/program that would be directly under the oversight of this Commission/Committee? *

Yes
No

Do You Agree to Conditions Set Forth Below *

Yes I Agree

In checking the box below the applicant recognizes that the Board of Trustees will make the final decision if I am appointed to serve as a Commission/Committee member. I certify that I meet the minimum qualifications for membership and that I understand the duties of members of the Commission/Committee to which I am applying I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that the Board of Trustees may review the information on this application for accuracy, including verification of information I have provided about my employment and educational history. I understand that the Board of Trustees may investigate my background, and I authorize the Board of Trustees and/or its agents to investigate my criminal history.

Committee and Commission Application

Submitting an Application

Applicants must be 18 years or older to apply and must provide the following information