CITIZENS ADVISORY COMMITTEE APPLICATION
& BACKGROUND CHECK FORM

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Citizens Advisory Committee Application and Background Check Form

Date

Name

Address

City

State

Zip Code

Phone

Experience and/or education in the area of interest

Time of day meeting availability

Committee/Area of Interest

By checking this box, I confirm that I am a permanent Mahoning County Resident *

Yes

Please be advised that all Citizen Advisory Committee applications will remain on file for a period of one year.

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