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.

If you are human, leave this field blank.