Board of Commissioners Application Form

If you are having trouble accessing the online form, you can contact us at:
(559) 263-1014
or email at
elections@FresnoEOC.org

Board of Commissioners Application Form

— APPLICANT INFORMATION —

Name

First Middle Last

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone

Alternative Phone

Date of Birth

Do you qualify as a low-income individual under the Federal Poverty Guidelines?

Yes

*See below to view the Federal Poverty Guidelines.

— EMPLOYMENT —

Must match the resume on the application.

Employer

Job Title

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

— COMMUNITY SECTOR REPRESENTATIVE —

If you are applying to be a Community Sector Representative, complete this section; otherwise skip to next section:

Organization Representing Name

# of years as a Fresno County Resident

Organization Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How will the organization and you be an asset to Fresno EOC?

List the reasons your organization is interested in Fresno EOC Board of Commissioners

Must submit a resolution of support for a two-year term from the agency, organization or group you are representing signed within 60 days of the due date. If the organization is a public entity, submit a letter from an authorized official.

— TARGET AREA REPRESENTATIVE —

If you are applying to be a Target Area Representative, complete this section; otherwise skip to next section. **See Target Area Map below, if you aren't certain which Target Area you live in.

Target Area You Live In

Target Area A

Target Area B

Target Area C

Target Area D

Target Area E

Target Area F

Target Area G

Target Area H

Please give a statement of qualifications/how you can contribute to Fresno EOC (This will be included on the ballot. You may use a separate sheet if necessary.)

If you wish to translate your statement to Spanish and/or Hmong, please provide it here (otherwise staff will translate your statement.)

Must attach documentation of age and residency.

Max. file size: 50 MB.

(i.e. copy of driver’s license. No P.O. Box allowed)

ADDITIONAL QUALIFICATIONS

All applicants must complete this section.

Briefly explain why are you interested in serving on the EOC Board of Commissioners?

Briefly explain your qualifications or areas of demonstrated expertise for the EOC Board.

What experience or special knowledge can you bring to the Fresno EOC Board of Commissioners?

— REFRENCES —

All applicants must complete this section.

Reference 1

Name

First Last

Organization

Position

Phone

Reference 2

Name

First Last

Organization

Position

Phone

DISCLAIMER AND SIGNATURE(Required)

I agree to the privacy policy.

I certify under penalty of perjury the above information is true and that:
• I am or will be 18 years of age or older;
• I am not an employee of Fresno EOC nor a member of the immediate family of an employee of Fresno EOC;
• I have read and understand the Fresno EOC Commissioner Job Description and have the capacity to serve;
• I understand there is a mandatory training for new commissioners, monthly board meetings and an annual board
retreat;
• I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any
federal department or agency;
• I have not been convicted of or had a civil judgment rendered against me for commission of fraud or a criminal offense
in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract
under a public transaction, for violation of federal and state antitrust statutes or for commission of embezzlement,
ADDITIONAL QUALIFICATIONS
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theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
• I have not been indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state or local) with commission of any of the offenses above; and
• I have not had any public transactions (federal, state or local) terminated for cause or default during the three years prior to the application.
• I am aware that I may be required to file Statements of Economic Interest forms (Form 700) disclosing certain types of information so that the public can be made aware of potential conflicts of interests. The types of disclosures are: Investments; Interests in Real Property held by a Business Entity or Trust; Investments Held by a Business Entity or Trust Income (other than loans and gifts); Income – Travel Payments, Advances, Reimbursements; Income Gifts; Business Positions; Commission Income Received by Brokers, Agents, and Salespersons; Income and Loans to a Business Entity or Trust Income from Rental Property.

Signature