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2. Disclaimer
   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
4. Board or Commission Applying For:*
   -- Select One --Planning CommissionHousing Authority

   Please submit one form for each board or commission.

6. New Appointment or Reappointment?*

   1. New Appointment

   1. Reappointment
8. First Name*
9. Last Name*
10. Email Address*
12. Street Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
20. Are you a Jefferson County resident?*

    1. Yes
    2. No
22. Current Job Title*
23. Current Employer*
25. Volunteer Positions or Board Membership*

    List organizational memberships and/or volunteer activities (including officer positions held). Include if these are past or present, length of service and whether or not they were located in Jefferson County.  

27. Interest*

    Why are you seeking this appointment?  Please explain why you feel you area a good candidate, including qualifications that meet the objectives of this board or commission.

29. Knowledge and Expertise*

    What will your knowledge and expertise bring to this board or commission?

31. Pressing Issues*

    In your opinion, what do you feel is the biggest challenge and/or biggest opportunity facing this board or commission.

33. Ag and Equine Heritage Issues*

    As it relates specifically to the preservation of agriculture and equine heritage in Jefferson County, what do you feel are the biggest challenges and/or biggest opportunities?

35. Airport Advisory Board Membership Criteria*

    Choose all that apply.

    1. I am a resident of Jefferson County
    2. I am a residential property owner residing within the airport influence area
    3. I am a business owner whose business resides within the airport influence area
    4. I am a current Rocky Mountain Metro Airport tenant
    5. I am employed at a jurisdiction (e.g. municipality or association) neighboring Rocky Mountain Metro Airport
37. Budget Advisory Committee Membership Criteria*

    Choose all that apply to you

    1. Experience overseeing budget production for a medium to large sized organization in Jefferson County
    2. Government budget experience
    3. Jefferson County resident
    4. Jefferson County business owner
    5. Member of a non-profit organization in Jefferson County
39. Budget Advisory Committee Experience*

    Members should have experience or expertise in local government or nonprofit budgeting or budgeting for a large organization. Please detail your experience and/or background as it relates to one or more of these areas.

41. CSAB Meetings*

    The Community Services Advisory Board (CSAB) meets monthly on the 3rd Tuesday of the month from 3 to 4:30 p.m. Additional meetings will be required during grant selection process. Will you be able to attend meetings more often than once per month?

    1. Yes
    2. No
43. Engineering Advisory Board Membership Criteria*

    Members shall be either a professional engineer registered in the State of Colorado, specializing in civil, structural or soil and foundation engineering, or a professional geologist as defined by C.R.S. 34-1-201, 1973, as amended. All engineers and geologists shall demonstrate substantial knowledge and expertise in the methods used to identify, investigate and mitigate damages due to steeply dipping claystone bedrock. Note: Jefferson County is seeking individuals that have a geological and geotechnical background in Designated Dipping Bedrock Area.

    1. Geologist
    2. Engineer
45. Equine and Agricultural Heritage Committee Membership Criteria*

    We are currently looking for representatives of neighboring communities of the Fairgrounds.

    1. Agriculture
    2. Equine
    3. Fairgrounds surrounding neighboring community
    4. Nonprofit
    5. Local Business
    6. Fairgrounds Advisory Committee
    7. Youth, Equine and Agriculture Working Group
47. Membership Criteria Detail*

    Please expand on how you represent the interest group(s) you selected.

49. Community Liaison*

    If selected, members will be considered a liaison to the interest group(s) you represent.  By clicking "Yes", you acknowledge and agree that you will bring information to/from the community interest group(s) as well as the commission meetings and information provided.

    1. Yes
    2. No
51. Community Engagement*

    Describe the ways you plan to engage the interest group(s) you are representing throughout your time on the commission.

53. Past Membership*

    Where you a member of either the Fairgrounds Advisory Committee or the Youth, Equine and Agriculture Working Group in 2020?

    1. Yes
    2. No
55. Letter of Support*

    Provide a letter of support from the interest group(s) you are representing.

    Note:  Documents should be combined into one file prior to uploading.

57. How did you hear about the Commission?*

    1. I belong to an organization that currently uses the fairgrounds.
    2. I host events at the fairgrounds.
    3. I have attended an event(s) at the fairgrounds.
    4. Fairgrounds Advisory Committee
    5. Youth, Equine and Agriculture Working Group
    6. I am a neighbor of the fairgrounds.
    7. I own/run/employed by a business close to the fairgrounds.
    8. I own/run/employed by a Jefferson County nonprofit.
    9. Other
59. Finance Expertise and Experience*

    Members shall be appointed based on their demonstrated expertise in 1) the laws and regulations applicable to local government; 2) county finance issues; and 3) knowledge of Certificates of Participation (COPs) which is preferred.

    Please describe your expertise and knowledge in these areas.

61. Foothills Housing Authority Board Membership Criteria*

    Members should have experience or expertise in general real estate finance, tax credit finance, policy, development, general accounting, banking, real estate and government. Please expand on your experience and/or background as it relates to one or more of these areas.

63. Service User*

    Do you use Jefferson County services (e.g. Human Services, Public Health, Parks, etc.)?

    1. Yes
    2. No
65. Are you a Jefferson County business owner?*

    1. Yes
    2. No
67. Subject Matter Expert*

    Do you have experience or expertise in diversity, equity, inclusion and/or community engagement?

    1. Yes
    2. No
69. Experience or Expertise*

    Provide details regarding your experience or expertise in the area(s) of diversity, equity, inclusion and/or community engagement.

71. Municipality Representation*

    Do you work for a Jefferson County municipality?

    1. Yes
    2. No
73. County Representing*
    -- Select One --Jefferson CountyClear Creek CountyGilpin CountyTeller County

    Which county will you be representing?

75. Private Sector Applicants*

    Workforce Innovation and Opportunity Act (WIOA) requires that private sector members be the owner, CEO or other individual with optimum policy-making or hiring authority. Do you fulfill this requirement?

    1. Yes
    2. No
77. Public Sector Applicants*

    Workforce Innovation and Opportunity Act (WIOA) requires that public member organizations have expertise in addressing employment, education or training needs for individuals with barriers to employment. Does your organization fulfill this requirement?

    1. Yes
    2. No
79. Wildfire Commission Membership Criteria*

    Which area do you represent?  Check all that apply.

    1. At-Large County Resident
    2. Subject Matter Expert (e.g. water district, conservation district, mountain parks, forest service, etc.)
81. Scheduling Conflicts*

    Do you have any scheduling conflicts that would impact your ability to attend meetings during the business week, 8:00am - 5:00pm?

    1. Yes
    2. No
83. Scheduling Conflicts - Detail

    Please provide more details regarding your scheduling conflicts.  

85. Equine and Ag Meetings*

    The commission will meet regularly once a year.  Should the Board of County Commissioners call upon members to investigate or research an issue, staff will decide how many additional meetings will be needed to provide a report and findings on the issue. Will you be able to dedicate the time for meetings and work needed to provide a report and findings to them?

    1. Yes
    2. No
87. Personal or Business Interests*

    Do you have any personal or business interests in matters before the board for which you are applying?

    1. Yes, I do have a personal or business interest.
    2. No, I do NOT have a personal or business interest.
89. Personal or Business Interests Details

    Provide more details regarding your personal or business interest.

91. Support Documentation

    Upload a resume, CV, or personal statement noting any additional information you wish to be considered.

    Note:  All documents will need to be combined into one document prior to uploading.

93. References*

    Please provide at least three references (professional and/or personal), including phone numbers. Do not include individuals related to you.

95. Applicant Certification - Duties & Obligations Acknowledgement*

    By clicking the box marked 'Yes' I acknowledge that I have read and understand the duties and functions of the board or commission, including the duties and obligations of persons serving as a member of this board or commission, and that the board or commission may, at times, require several hours per week outside normally scheduled meetings and hearings to perform site visits, review staff reports, attend programs, workshops, or training.

    1. Yes
    2. No
97. Applicant Certification - Public Records Acknowledgement*

    By clicking the box marked 'Yes' I acknowledge that I understand that the Colorado Public Records Law may require that certain information contained on this application be accessible to the general public, except when specifically made confidential by statute.

    1. Yes
    2. No
99. Applicant Certification - Membership Appointment*

    By clicking the box marked 'Yes' I acknowledge that I understand my appointment will begin January 1, 2019.

    1. Yes
    2. No
101. Electronic Signature Agreement*

     I do hereby certify that to the best of my knowledge and belief the information contained herein is true and correct, and that I have fully disclosed any personal or business interests in matters before the board or commission for which I am applying.

     1. I have read and understand the above
103. Electronic Signature*
Leave This Blank:


105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit

* indicates a required field