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2. Board Applying For:*
4. Name*
5. Date
   Date
7. Address*
9. Email Address*
11. Phone Number*
13. Educational Background:
15. High School Name and Location
16. Graduated/Degree
18. College Name and Location
19. Graduated/Degree
20. Major
22. Other Education Name and Location
23. Graduated/Degree
24. Emphasis
26. Do you reside inside the corporate limits of the City of Independence?

    1. Yes

    1. No
28. If no, do you reside within 3 miles of the corporate limits of the City of Independence?

    1. Yes

    1. No
30. What experiences have you had that you feel would assist you as a board member?
32. Why do you want to become a member of the board?
34. Do you feel that there are any issues needing immediate attention by the board? If so, please explain.
36. Other comments:
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field