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2. First Name*
3. Last Name*
5. Phone*
6. Email*
8. Street Address*
9. Zip*
11. Are you a resident of Valparaiso? Note, most appointments require Valparaiso residency.*

    1. Yes
    2. No
12. If you are a resident, how long have you lived in Valparaiso?*
14. Current Employer*
15. Position
17. What is your political affiliation? Certain seats may be party-specific.

    Generally, party affiliation is determined by your ballot selection in the last primary election.

    1. Democrat
    2. Republican
19. The HRC meets quarterly in the evening. If appointed, are you able to attend the days/times of the regularly scheduled meetings?*

    1. Yes
    2. No
21. Please provide any educational background and professional experience that you believe will help the City Council evaluate your application.
23. Why do you wish to serve on the HRC?
25. What personal experiences do you have that may aid your participation on the HRC?
27. Have you ever served on a public or private Board/Commission/Committee? If so, describe your experience during your term and any positive accomplishments.
29. If you could improve one thing in Valparaiso, what would it be, and why?
31. Have you reviewed Ordinance 8 and the Human Rights Ordinance? Do you have any questions?

    Both of these ordinances can be found on the Human Relations Council webpage.

33. Form Submission
    Upon submission of this form, it becomes public record. Forms will be reviewed by the Mayor and City Council as vacancies occur. Note that some boards/commissions have longer terms than others and vacancies may not occur frequently.
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field