County Mayor

County Mayor

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Contact Info.

County Mayor
1 Millennium Plaza
Suite 205
Clarksville, TN 37040


Phone: 931-648-5787
Email: [email protected]

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Application to Express Interest in Serving on a Committee or Board

 

Montgomery County employees and those who contract with the County are not eligible to serve on boards and commissions.

Committee or Board Information

I am applying for:

Contact Information

Full Name

Email

Phone Number

Address

Demographic Information

Gender

Ethnicity

If you selected "other" for the ethnicity question, please describe your ethnicity here:

Employment Information

Employment Status

Current employer

Title or Position

Business Address

Community Activities/Organizational Affiliations

Relevant Skills and Qualifications

Disciplinary History

Have you ever been convicted of a felony?

Yes No

If yes, please explain

Have you ever had a professional/ occupational license revoked, or suspended as a result of disciplinary action?

Yes No

If yes, please list the board, commission, or committee

Do you currently, or do you intend to, have any contractual or other arrangement with the County or any of its agencies which would result in a direct or indirect benefit to you?

Yes No

If yes, please explain

Acknowledgement

By submitting this application, I understand that any misrepresentation of the information I have provided could result in my non-selection as a board/committee member. I understand that the information I have provided and the contents of my background report may be disclosed to authorized employees, officials, and/or duly accredited representatives of Montgomery County as necessary throughout the applicant selection process. I hereby release Montgomery County and any individual, including records custodians, from any liability for damages of whatever kind or nature which may at any time result to me on account of compliance or any attempt to comply with this authorization.