Form Center

2. Please select the name of the committee, board, or commission for which you would like to be considered for appointment.
   -- Select One --Aging and Disability Resource Center Serving Calumet, Outagamie and Waupaca Counties Advisory Committee Aging and Disability Resource Center/Long Term Support Advisory CommitteeBrillion Library BoardCalumet County Traffic Safety CommissionChilton Library BoardCounty Children with Disabilities Education BoardCounty Parks CommissionFox Valley Workforce Development BoardGlacierland Resource and Conservation Development CouncilHealth and Human Services BoardLand Information CouncilLocal Emergency Planning CommitteeManitowoc-Calumet Counties Library Systems BoardNew Holstein Library BoardPlanning, Zoning, and Farmland Preservation CommitteeRevolving Loan Fund CommitteeVeterans Service CommissionZoning Board of Adjustment
4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Phone*
14. Email address
16. Occupation
17. Are you a Calumet County resident?*

    1. Yes

    1. No
19. Reside in*
    -- Select One --City of AppletonCity of BrillionCity of ChiltonCity of KaukaunaCity of KielCity of MenashaCity of New HolsteinVillage of HarrisonVillage of HilbertVillage of PotterVillage of SherwoodVillage of StockbridgeTown of Brillion Town of BrothertownTown of CharlestownTown of ChiltonTown of HarrisonTown of New HolsteinTown of RantoulTown of StockbridgeTown of Woodville
20. Are you 18 years of age or older?*

    1. Yes

    1. No
22. Have you previously served on any Calumet County committees, boards or commissions?

    1. Yes

    1. No
23. Have you ever been convicted of a felony?*

    1. Yes

    1. No
25. Please list the committees, boards, and commissions on which you have previously served.
27. Please list the qualifications you possess that are relevant to the committee, board, or commission for which you are applying. *
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field