The City currently has three standing Commissions/Committees: the Planning Commission, the Public Safety Advisory Commission (PSAC) and the Measure Z Citizen Committee. All commissions/committees consist of five members who shall not be officials or employees of the City. Applicants for the Planning/Public Safety Advisory Commission shall legally reside within the City limits or be the owner of a business that is established and currently licensed within the City limits (LEMC Section 2.24.020). Applicants for the Measure Z Citizen Committee must legally reside within the City limits. Each commission/committee serves as an advisory body to the City Council on policy matters or reviewing specific issues as directed by the City Council or prescribed by law. Currently, all Planning and Public Safety Advisory Commissioners are appointed at-large by a City Council Subcommittee. However, members of the Measure Z Citizen Committee are appointed by-district by their elected council representative. 

Instructions: Please answer each question completely. This application will be maintained until December 31st of each year. After December 31st, it is necessary to file a new application for another year of eligibility. Please be advised that the City Clerk’s Department uses Voter Registration information for verification of residency. Note: This application is subject to the Public Records Act and may be released to the public.

Additional Resources to Assist in Completing Application: 

City Map: To view a map showing the City limits, please click here.  

City Council Districts: To find out which City Council District you live in, please click here.

1

Commission/Commitee Applying For:

 *

Commission/Commitee Applying For:

Planning Commission	PSAC Commission
Measure Z Citizen Committee

2

Applicant Eligibility

 *

City Resident

Business Owner

3

Applicant Information

 *

Applicant Information

Last Name	First Name
Home Address	City
State	Zip Code
Phone Numberext.	Email
Length of Residency in Lake Elsinore	Length in California
What City Council District do you live in? See link above to verify.

4

Business Information (if applicable)

Business Information (if applicable)

Business Name	Business Type
Business Address	Lake Elsinore Business License Number
Expiration Date	Phone Number
Date Business Established

5

Education Information

 *

Education Information

Name of School Attended	City & State
Degree Earned	No. of Units Completed
Name of School Attended	City & State
Degree Earned	No. of Units Completed
Certificates Attained

6

Do you have Economic Interests, such as income, investments, real or personal property, or outstanding loans which might present a potential conflict of interest?

 *

Yes

No

7

Work History

Work History

Current Employer	Address
From	To
Position	Duties Performed
Previous Employer	Address
From	To
Position	Duties Performed

8

References (preferably local residents or stakeholders who are qualified to comment on your capabilities)

References (preferably local residents or stakeholders who are qualified to comment on your capabilities)

Name	Address	Phone Numberext.
Name	Adress	Phone Numberext.
Name	Address	Phone Numberext.

9

Community Service Participation (please describe types of service you have performed, if any)

Community Service Participation (please describe types of service you have performed, if any)

Organization	Types of Service
Organization	Types of Service
Organization	Types of Service
Additional Documentation Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

10

Are you an Officer or Member of a policy-making board of a non-profit organization which receives funding from the City?

 *

Yes

No

11

If Yes, please list all organizations

If Yes, please list all organizations

Organization	Position
Organization	Position
Organizaton	Position
Additional Information Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

12

Have you ever been convicted of violating any Federal, State, County or Municipal law, regulation or Ordinance, excluding minor traffic violations?

Have you ever been convicted of violating any Federal, State, County or Municipal law, regulation or Ordinance, excluding minor traffic violations?

Yes	No
If Yes, Please explain

13

Why are you interested in serving on this Commission/Committee?

 *

Please list reasons for serving.

14

Please list any qualifications you may have to serve on the Commission/Committee you are applying for, i.e. education, related service or work experience, budgeting or financial experience, community involvement, etc. (For example, if you are applying for the Measure Z Citizen Committee, please list any financial or budgeting experience)  

 *

Please list all qualifications.

15

Please note: Appointees will be required to take an Oath of Office and file a completed Statement of Economic Interest form, if appointed to a position specified in the City’s Conflict of Interest Code. Appointees are not considered to be City employees for purposes of benefits, such as workers compensation and health insurance.

16

Applicant's Declaration and Signature

I certify under penalty of the perjury laws of the State of California that all information on this form is true and correct.  By typing my name and the date completed on this form, I am affirming my intent to be a candidate for appointment to a Commission for the City of Lake Elsinore. If appointed I pledge to follow the laws of the City of Lake Elsinore, the policies as set forth by the City Council and to conduct myself in such a manner as to be a good representative of the City.

 *

Name

Date

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

To prevent spam we utilize a verification code system. Please enter the code as it is shown in the box below:

 

Code:

Page 1 / 1