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Statement of Interest - Serving as Associate Member (non-voting) on Town Ad Hoc Committee
Please fill in the following personal information:
Today's Date
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(mm/dd/yyyy)
First Name
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Middle Initial
Last Name
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Ad Hoc Committee of Interest
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Email Address
Home Address
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P.O. Box
Primary Phone Number
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Secondary Phone Number
Age
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Please Select…
14
15
16
17
School
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Grade
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Parent/Guardian's Name
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Parent/Guardian's Phone Number
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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
G
uidelines for Ad Hoc Committees with Associate Members/Student Representatives
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.
I am the Parent/Guardian, signing on behalf of the child/student
Please send a confirmation email to the address below: