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Sunny Oaks

50 year Celebration!!

Main Building

Happy Anniversary!

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Juvenile Department Staff

Administration
Jodi Merritt
Director	Merritt.Jodi@polkcountyor.us

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LADPC Application Form

Local Alcohol and Drug Policy 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?

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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?

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Yes

No

If yes, which

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

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Yes

No

If yes, which

Please list areas of special interest

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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 *