3. 
6. PUEBLO COUNTY and CITY OF PUEBLO PARTNERSHIP
   COMMUNITY SERVICES ADVISORY COMMISSION (CSAC)
   Application for Appointment
8. Contact Information
10. DATE
    DATE
12. FIRST NAME
13. Middle Initial
14. LAST NAME
16. HOME ADDRESS
18. CITY
19. STATE
20. ZIP
22. HOME PHONE
23. WORK PHONE
24. CELL PHONE
26. E-MAIL ADDRESS
28. Questionnaire
    Please complete the following general information.
30. I believe that I am qualified to represent the following group(s):
    
    Please select your primary area of interest.
    Then numerically rank any secondary areas of interest in order of preference.
32. ARTS & CULTURE
34. HEALTH
36. Primary
    -- Select One -- Disabled Early Childhood Development Economic Development Education Faith Based (clergy, Interfaith Coalition, etc)
38. Primary
    -- Select One -- Mental Health Private Foundations Seniors Sports and Recreation Youth
40. 2
    -- Select One -- Disabled Early Childhood Development Economic Development Education Faith Based (clergy, Interfaith Coalition, etc)
42. 2
    -- Select One -- Mental Health Private Foundations Seniors Sports and Recreation Youth
44. 3
    -- Select One -- Disabled Early Childhood Development Economic Development Education Faith Based (clergy, Interfaith Coalition, etc)
46. 3
    -- Select One -- Mental Health Private Foundations Seniors Sports and Recreation Youth
48. 4
    -- Select One -- Disabled Early Childhood Development Economic Development Education Faith Based (clergy, Interfaith Coalition, etc)
50. 4
    -- Select One -- Mental Health Private Foundations Seniors Sports and Recreation Youth
52. 5
    -- Select One -- Disabled Early Childhood Development Economic Development Education Faith Based (clergy, Interfaith Coalition, etc)
54. 5
    -- Select One -- Mental Health Private Foundations Seniors Sports and Recreation Youth
56. Please state why you would like to serve on the Pueblo County and City of Pueblo Partnership
    Community Services Advisory Commission:
58. Please describe your experiences related to the group(s) that you are
    proposing to represent on the Community Services Advisory Commission.
60. Please list your experiences serving on community boards.
    Include approximate service dates:
62. Please list all affiliations with community human services agencies, quality of life issues, arts and culture activities, economic development programs, recreational activities, etc. within the Pueblo Community.
64. List any other items that might be useful in consideration for your appointment to this Commission.
68. Upload Resume
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit Submit and Print

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