* Name:

* Address:

* Email:

Telephone (home):

Telephone (cell):

* Are you a registered voter in Maynard?
YesNo

* First choice:
---Affordable Housing TrustBoard of AssessorsCable Access Board of DirectorsCommunity Preservation CommitteeConservation CommissionCouncil on AgingCultural CouncilEconomic Development CommitteeFinance CommitteeBoard of HealthHistorical CommissionMaynard Green Communities Committee Parking AuthorityPlanning BoardRecreation CommissionRegistrars of VotersSesquicentennial Planning CommitteeZoning Board of AppealsOther (provide details below)

Second choice:
---Affordable Housing TrustBoard of AssessorsCable Access Board of DirectorsCommunity Preservation CommitteeConservation CommissionCouncil on AgingCultural CouncilEconomic Development CommitteeFinance CommitteeBoard of HealthHistorical CommissionMaynard Green Communities Committee Parking AuthorityPlanning BoardRecreation CommissionRegistrars of VotersSesquicentennial Planning CommitteeZoning Board of AppealsOther (provide details below)

* Why do you want to serve on this particular Board, Committee, or Commission?

* Please state three attributes that you can bring to this Board, Committee, or Commission

Have you attended any meetings of this Board, Committee, or Commission? (Optional)

Are there any changes you would like to make if you are appointed to this Board, Committee, or Commission?

What is your availability? Nights? Weekends?

* Do you regularly attend Town Meeting?
YesNo

* Have you ever served on a Board, Committee, or Commission in the Town of Maynard?
YesNo

If you answered “yes” above, please list the Boards, Committees, and/or Commissions you have served on:

Who is your present employer and position (optional)

* Please list any skills or specialized knowledge you can bring to this Board, Committee or Commission.

* Please provide your educational background: level, degrees, etc.

Please list any professional affiliations (Optional):

Please list any other specialized interests and hobbies (Optional):

Please provide any additional information you feel may be helpful while reviewing your application.

I will read a copy of the Massachusetts General Laws Chapter 268A “Conflict of Interest” provided by the Town Clerk, if appointed, and to the best of my ability agree to abide by the provisions of the statute.

I agree.