The City of Lake Elsinore Planning/PSAC Commission’s consist of five members who shall not be officials or employees of the City and shall legally reside within the City limits of the City or be the owner of a business that is established and currently licensed inside the City limits (LEMC Section 2.24.020).  Members are appointed to four year terms, by the City Council.

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.

1

Commission Applying For:

 *

Planning Commission

PSAC Commission

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

4

Business Information

Business Information

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 (Local Residents who are qualified to comment on your capabilities)

References (Local Residents 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

Interest for Serving on a Commission

 *

Please list reasons for serving

14

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.

15

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

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