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2. Name:*
4. Home Address:*
6. City*
8. Home Phone:*
9. Additional Phone:
11. Email Address:*
13. Please select the Board or Committee you are submitting this application for:*
    -- Select One --Aging Services Advisory CouncilBoard of Elections and RegistrationBoard of HealthBoard of Tax AssessorsBryan-Lang Historical Archives BoardCoastal Area District Development Authority (CADDA)Coastal Georgia Resource Conservation Development CouncilCoastal Regional Commission Board of DirectorsCoastal Workforce Development Board (CWDB)Coastal Workforce Service BoardDepartment of Behavioral Health and Developmental Disabilities (DBHDD) - Region 5 Advisory CouncilDepartment of Family and Children Services BoardGateway Community Service BoardGeorgia Forestry BoardJoint Development AuthorityPlanning CommissionPublic Service Authority (PSA) BoardSt. Marys River Management CommitteeThree Rivers Regional Library Board
15. Are you currently serving on a County Board(s)?*

    1. Yes
    2. No
17. If yes, which board(s) do you serve?
19. Are you a resident of the County?*

    1. Yes
    2. No
21. What District do you live in?*

    1. District 1
    2. District 2
    3. District 3

    1. District 4
    2. District 5
    3. I do not live in Camden County.
23. I...*

    Please select all options that apply to you.

    1. I own property in Camden County.
    2. I own a business in Camden County.

    1. I work in Camden County.
    2. None of the Above
25. If needed, you may click on the link below to find your District on the interactive map.
    District Map
27. Do you hold a public office?*

    1. Yes
    2. No
29. Are you employed by Camden County?*

    1. Yes
    2. No
31. Have you been convicted of a misdemeanor or felony, excluding civil traffic infractions? (Note: A DUI and/or revoked license are NOT "civil traffic infractions" and must be reported.)*

    1. Yes
    2. No
33. If yes, please explain:
35. Do you have any potential conflicts of interest that may arise from time to time if you serve on one of these boards? (A conflict of interest would be anything that inures to your benefit, your employer's benefit, or a member of your family's benefit. Note: Having a potential conflict of interest does not necessarily exclude you from serving on a board.)*

    1. Yes
    2. No
37. If yes, please explain:
39. Please list any community involvement, special skills, talents, experience, expertise or other qualifications that you would bring to theboard(s) for which you are applying:*
41. I hereby declare that the information provided by me in this application is true, correct, and complete to the best of my knowledge. I understand that, if chosen, any misstatement or omission of fact on this application shall be considered cause for ineligibility for appointment. Applicants are considered for all appointments without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or disability.
43. Electronic Signature Below: *
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

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