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Citizen Board and Commission Application

  1. Gender

  2. Do you live in Winston-Salem City limits?

  3. Do you live in Forsyth County?

  4. Are you a graduate of the City of Winston-Salem University?

  5. Education

  6. Please include expiration date.

  7. Are you willing to serve on any other Board/Commission?

  8. Are you interested in serving in any other community volunteer activities?

  9. List Two Professional References

  10. Affirmation of Eligibility

  11. Has any formal charge of professional misconduct, criminal misdemeanor, or felony ever been filed against you in any jurisdiction?

  12. Is there any possible conflict of interest or other matter that would create problems or prevent you from fairly and impartially discharging your duties as an appointee to a Board/Commission?

  13. I understand this application is public record, and I certify the facts contained in this application are true and correct to the best of my knowledge. I authorize and consent to background checks and to the investigation and verification of all statements contained herein. I further authorize all information concerning my qualifications to be investigated and release all parties from all liability for any damages that may result from this investigation. I understand and agree any misstatement or conduct will be cause for my removal from any board or commission.

  14. Return Completed Form

    Mayor’s Office
    P.O. Box 2511
    Winston- Salem, NC 27102
    Phone: 336-727-2058
    Fax: 336-748-3241
    Email the Mayor's Office

    Please include your resume when submitting your application.

  15. Note: Applications will be kept on file for two years from the date of application.

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  17. This field is not part of the form submission.