County of Santa Clara

Office of the Clerk of the Board of Supervisors

County Government Center, East Wing

70 West Hedding Street

San Jose, California 95110−1770

(408) 299−5001   FAX 298−8460   TDD 993−8272

Web site: http://cob.sccgov.org

Phyllis A. Perez

Clerk of the Board

Application for Advisory Appointment

Fields marked with an asterisk (*) are required

Select One

Mr.

Mrs.

Ms.

Dr.

Application Date

*Last Name

Middle Name

*First Name

Address

*Home Phone 

City

State

Zip

Business Phone

E−mail Address

Fax No. 

Years

Months

How long have you been a resident of the County of Santa Clara?

In which supervisorial district do you live?

Don't know which district you live in? Use our online

Are you a County employee?

Yes

No

If yes, in which department

Education (check all that apply):

High School

College Degree

Masters Degree

Doctoral Degree

Other

Occupation

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Advisory Appointment Application

04/07/2008 05:44:44 PM

On which Advisory Boards, Commissions or Committees  would you like to serve? (Please  list in order of preference)

Why do you want to become  a member of a County  Advisory Board or  Commission?

Please list your qualifications  thought applicable for  appointment.

Are there any special interests  or activities that you wish to  bring to attention of the Board of  Supervisors?

Do you have any obligations  that might affect your  attendance at scheduled  evening meetings?

This space is provided for any  additional information you may  have about yourself or the  position being sought.

Please provide three references:

Reference 1 Name:

Reference 2 Name:

Address Line 1:

Address Line 1:

Address Line 2:

Address Line 2:

Phone:

Phone:

Reference 3 Name:

Address Line 1:

Address Line 2:

Phone:

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Advisory Appointment Application

04/07/2008 05:44:44 PM