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Statement of Interest - Serving on a Town Board or Commission
Please fill in the following personal information:
First Name
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Middle Initial
Last Name
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Board/Commission/Committee of Interest
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Connection to Ellington*
Select all that apply​
Resident
Business Owner
Non-Profit Representative
Email Address
Home Address
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P.O. Box
Primary Phone Number
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Secondary Phone Number
Business/Work Address
City/Town
State
Zip Code
Are you a registered voter?*
*Per Section 902 of the Town Charter, no person shall be eligible for appointment to any regular town board or commission, except the Building Code Board of Appeals or any Ad Hoc Committee, who is not, at the time of his appointment, an elector of said town and any person ceasing to be an elector of said town shall thereupon forfeit his membership on said board or commission.
Yes
No
Affiliation
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Please Select…
Democrat
Republican
Unaffiliated
Other
Other Parties
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Please Select…
Green
Independent
Libertarian
Working Families
Briefly explain your reasons for being interested in serving in this capacity
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Note any qualifications you have which you think will be an asset to the Town Agency in which you are interested
Requirement
Please be advised that all town officials must comply with Section 1203 of the Town Charter-Conflict of Interest: "Any elected or appointed officer, any member of any board or commission, or any employee of the town who has a financial interest direct or indirect, in any contract, transaction or decision of any officer or agent of the town or any board or commission, shall disclose that interest to the Board of Selectmen for recording upon their official records and any such person shall be thereby disqualified from participation in the awarding, assignment or discussion of any contract, transaction, or decision. Violation of this provision shall be grounds for the removal of any such person." Should you be appointed to serve on a town board, commission or agency, you would be required to comply with these regulations.
By providing my electronic signature below I certify that I understand and accept Section 1203 of the Town of Ellington Charter and Attendance Policy (printed on back) and agree to abide by such.
Attendance Policy - Appointed Board, Commission and Committee Members
I have read and agree to abide by the Attendance Policy
Electronic Signature
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required
By typing your electronic signature, you give permission for the Town of Ellington to authorize this as a signature.
Today's Date
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(mm/dd/yyyy)
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