LAPPC Application Form

Local Addiction Prevention Planning Committee

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Date

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Personal Information

First Name *

Last Name *

Address *

City *

State *

Zip *

Home/Cell Phone Number *

Mailing Address (if different)

Mailing Address (if different from Address)

Mailing City

Mailing State

Mailing Zip

Business Address

Business Phone Number

Occupation *

Email Address *

Residency Information

Are you a registered voter in Polk County?

Select One *

Yes

Education and Hobbies

High School

College

Trade or Business School

Hobbies

Organization Membership Information

Are you currently a member of any Organizations, Boards, Commissions or Committees?

Select One *

Yes

If yes, which

Have you previously been a member of any Organizations, Boards, Commissions or Committees?

Select One *

Yes

If yes, which

Please list areas of special interest

Please enter basic resume information below

Electronic Signature Agreement

By signing the box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

Electronic Signature *

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