2. PLEASE READ: IMPORTANT INFORMATION

   If you have an interest in serving on one or more of the Boards and/or Commissions of the City of Canton, please complete the below application.

   The City of Canton is an equal opportunity employer and will not use any of the information you provide to discriminate against you on the basis of race, color, religion, sex, national origin, handicap, age or ancestry.  The below questions are necessary to ensure the City is in compliance with the ordinances of each Board and Commission. 

4. First Name*
5. Last Name*
7. House Number*
8. Street Name*
9. Direction*
11. City*
12. State*
13. Zip Code*
15. How long have you lived at this residence?*
16. How long have you lived in Stark County?*
18. Phone Number*
19. Email address*
21. Current Employer*
22. Employer Address*
24. Date of Birth*
    Date of Birth
25. Sex*
    -- Select One --FemaleMaleTransgender WomanTransgender MaleNon-BinaryAgender (don't identify with any gender)Gender not listed.Prefer not to state.
26. Race*

    1. White
    2. Black/African American
    3. Hispanic or Latino
    4. Asian
    5. Other
28. Are you a registered voter?*
    -- Select One --YesNo
29. If yes, County of Registration?*
30. Party-Affiliation*
    -- Select One --DemocratRepublicanUnaffiliatedOther
32. Boards and Commissions of interest. Check all that apply.*

    1. Architectural Review Board
    2. Board of Building Appeals
    3. Civil Service Commission
    4. Community Improvement Corporation
    5. Community Relations
    6. Construction Board
    7. Fair Housing Commission
    8. Health Board
    9. Income Tax Board of Review
    10. Investment Board

    1. Neighborhood Commission
    2. Parks Commission
    3. Planning Commission
    4. Records Commission
    5. Stark County Regional Planning Commission
    6. Systems Planning Board
    7. Tax Inventive Review Board
    8. Tree Commission
    9. Zoning Board of Appeals
34. Do you currently serve on a Board or Commission?*
    -- Select One --YesNo
35. Please list Board or Commission you currently serve on.
37. Have you served on a Board or Commission in the past?*
    -- Select One --YesNo
38. What Board or Commission have you served on in the past?
40. Please list any certifications, licensures, or qualifications that pertain to the Board or Commission to which you are applying for.
42. You may upload certification, licensures here.
44. Have you ever been convicted of a crime or arrested for a crime for which your were not convicted, excluding minor traffic offenses?*
    -- Select One --YesNo
45. If yes, please explain.
47. Are your federal, state and local taxes current?*
    -- Select One --YesNo
48. If no, please explain.
50. Have you ever received, other than as an employee, or has any business that you owned or of which you were the majority shareholder, ever received any income from the city?*
    -- Select One --YesNo
51. If yes, please explain.
53. Do you have, or have had, any personal fnancial or business interest or dealings that might present a conflict of interest with your proposed appointent?*
    -- Select One --YesNo
54. If yes, please explain.
56. Education & Training
58. High School Attended:*
59. Did you graduate?*
    -- Select One --YesNo
60. Highest grade completed?*
    -- Select One --1211109Other
61. Obtained GED?
    -- Select One --YesNoNot applicable
63. Continuing Education
64. Major/Course of Study
66. Please list relevant work experience.
68. Electronic Signature Agreement*

    By checking the "I agree" box below, you certify that all of the answers and statements on this form are true, complete and correct to the best of your knowledge and recollection and are made in good faith.

    1. I agree.
70. Electronic Signature
72. Electronic Signature Agreement*

    By checking the "I agree" box below, you understand that any information provided  to the City of Canton may be a "public record" under Ohio law.  Therefore, you agree to waive any right to privacy of any information provided herein, and you authorize the City of Canton to investigate any of your responses.  

    1. I agree.
74. Electronic Signature
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit Submit and Print

* indicates a required field