CITIZEN SERVICE INFORMATION FORM Name (Print): Date: Last

CITIZEN SERVICE INFORMATION FORM
Name (Print): ______________________________________________
Last
First
Middle
Date: ___________________
Home Address: _______________________________________________________________________
Business Name: _______________________________________________________________________
Business Address: _____________________________________________________________________
Telephone (Home): _______________________________ (Work): _____________________________
Email Address: _______________________________________________________________________
How long have you lived in the City of Fort Atkinson? ________________________________________
Which Boards, Commissions and/or Committees interest you? __________________________________
_____________________________________________________________________________________
Please give a brief overview of your background, experience, interest or concerns in the above areas:
References:
1.
___________________________________________________
___________________________________________________
___________________________________________________
Phone: ___________________
2.
___________________________________________________
___________________________________________________
___________________________________________________
Phone:___________________
___________________________________________
Signature
Return this form to:
City Manager’s Office
101 North Main Street
Fort Atkinson WI 53538
[email protected]