HomeMy Public PortalAboutCommittee and Commission ApplicationCity of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
Dear Applicant,
Thank you for your interest in serving on a commission or committee at the City of Riverdale, Iowa.
We appreciate your willingness to serve your community!
Please complete this application and drop it off at City Hall, mail it to City Hall, 110 Manor Drive,
Riverdale, Iowa 52722, or email it to mayor@riverdaleia.org, at your earliest convenience.
Respectfully,
Mayor & Council
City of Riverdale, Iowa
City of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
City of Riverdale, Iowa
Commission & Committee Application Form
CONTACT INFORMATION
Name
Address
Email
Primary Phone Receive texts? ☐Yes ☐No
Secondary Phone Receive texts? ☐Yes ☐No
Preferred Communication Method ☐Call ☐ Text ☐Email ☐ Snail Mail
DEMOGRAPHIC INFORMATION
Iowa Code 69.16A requires all boards to be equally diverse between men and women. Further, it is the intention of the Mayor and
Council of the City of Riverdale, Iowa, to represent the diversity of the community including ethnic, age, educational, and professional
backgrounds, as well as being inclusive of representation from as many neighborhoods as possible. You MUST be a resident of the
City and 18 years old to be appointed to a board, commission, or committee.
Gender/Gender Identity ☐Male ☐Female
Race/Ethnicity
☐American Indian or Alaska Native ☐Black or African American
☐Asian ☐Caucasian
☐Hispanic or Latino ☐Two or more races
Age
☐18 - 27 ☐48 - 57
☐28 - 37 ☐58 - 67
☐38 - 47 ☐68+
Which neighborhood do you live in?
☐Bellingham/Belmont/State/Valley ☐ Pleasant Hills
☐Fenno Addition ☐Woods Estates
☐Haven's Acres
EXPERIENCE & EDUCATION
Employer
Department
Title
Education
☐None ☐Undergraduate degree
☐High school diploma ☐Graduate level degree
☐Apprenticeship/skills training ☐ Professional/terminal degree
☐Vocational/technical degree ☐Other: ____________________________________
List any current professional affiliations (chambers of commerce, clubs, organizations):
City of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
Check all the following boards, committees, and commissions of interest:
☐Planning & Zoning ☐Sewer Commission
☐Board of Adjustments ☐Budget Committee
Are you interested in running for or being appointed to Council? ☐Yes ☐No
List boards and commissions you've served on in the past (City of Riverdale or otherwise):
What contributions can you make to a board or commission? Or, what is your reason for applying?
What is your favorite thing about being a resident of Riverdale?
FINANCIAL DISCLOSURE
Check all the following that apply to you:
☐I own part or all of a business that does, or could potentially do, business with the City of
Riverdale.
☐I am employed by a business (whether part or full-time) that does, or could potentially do,
business with the City of Riverdale.
☐Someone in my household owns all or part of a business that does, or could potentially do,
business with the City of Riverdale.
☐Someone in my household is employed by a business (whether part or full-time) that does, or
could potentially do, business with the City of Riverdale.
☐I, or someone in my household, receives income from a business under circumstances other than
those listed above but from a business that does, or could potentially do, business with the City of
Riverdale.
City of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
If you checked any of the items in the previous question, list the household member, business, and
nature of the relationship.
ATTESTATION & SIGNATURE
By signing this application, I indicate that I am interested in serving the City of Riverdale, Iowa, on a
board, commission, or committee and that the answers in this application are true and accurate to
the best of my knowledge.
Signature: Date: