Title: Mr. Ms. Mrs. Name: Employer:

Please check preferred mailing address:
Home   Business   Position:

Business Address:
Number:   Direction: N S E W Street: Type: Unit Type: Unit Name:
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Home Phone: Business Phone:

E-mail Address

Do you live in the Springfield City Limits? Yes No If yes, how long? year(s)

Special qualifications (include past board service) If submitting a resume, attach to an e-mail sent to city@ci.springfield.mo.us

Educational Background

Community activities and offices held

References