Personal Information

First Name:*

Middle Initial:

Last Name:*

Home Address:*

Town:*

State:*

Zip Code:*

Day Phone Number: (xxx-xxx-xxxx)

Evening Phone Number:(xxx-xxx-xxxx)

Email Address:*

Residency Information

Number of Years Living in Needham:

Are you a registered voter?*

Yes

No

Are you currently serving or have you served on other Boards, Commissions, or Committees?*

Yes

No

If yes, which:

Committees of Interest (if known):

Committee Vacancy for Consideration:

Please describe your background or training (work and/or life experience) that relates to your interest in government.*

Please describe any Town government experience (paid or volunteer) you have.*

Please describe any community experience you have. Have you served on any other community organization(s)? have you served as an officer for any organization?*

Please include any additional information for the Town to consider.

Organization Membership Information

Please explain any restrictions on your availability to attend Committee meetings?

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