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2. Applicant Information
4. First Name*
5. Last Name*
7. Address*
8. City*
9. State*
10. Zip Code*
12. Home / Cell Phone*
13. Email Address*
14. Length of Bentonville Residency*
16. Employer*
17. Occupation*
18. Business Phone*
20. If married, spouse's first and last name
21. First Name
22. Last Name
26. Board Selection and Qualifications
28. 1. What are your qualifications for serving on this commission or board, including education and subject matter expertise?*
30. 2. Why would you like to be considered for appointment to this commission or board?*
32. 3. What do you hope to be able to contribute? *
36. Qualifications for Serving
    Please read the Qualifications for Serving provided below. These are the general qualifications to serve on any board or commission of the City of Bentonville.
38. 
40. I have read the above qualifications to serve on a city commission or board.*

    1. Yes
    2. No
44. Restrictions on Appointees
    Please read the Restrictions on Appointees provided below. Then type in your name and date to confirm that you are aware of and, if appointed, agree to the following rules.
46. 
48. Agreement to Abide by Restrictions on Appointees*
    By typing in your name above, you confirm your awareness and agreement to follow the above listed restrictions on appointees.
49. Date*
    Date
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51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit Submit and Print

* indicates a required field