Last Day to apply for the Local Board of Tax Review Member Position

The Village of Middlefield Application for Committee Appointment Name of Candidate:____________________________________ Address:_____________________________________________ ____________________________________________________ Telephone:________________home___________________cell Email: ______________________________________________ Committee/Board Applying For: __________________________ 1) Are you related to any current employee of the Village? ___Y __N If Yes, give name and position: _____________ ____________________________________________________ 2) Have you ever been convicted of a violation of any law, other than minor traffic offenses? (OVI convictions must be disclosed) ___Y __N If yes, please list_________________ ____________________________________________________ ____________________________________________________ 3) STATEMENT: Please provide a brief statement as to why you feel you are qualified for this appointment. If you are seeking re-appointment, please indicate what your contributions have been to the committee during the time of your service. ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Signature of Applicant:______________________ Date:_______ Village of Middlefield * 14860 N State Avenue, Middlefield, Ohio 44062 *