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2. SPOKANE REGIONAL LAW AND JUSTICE COUNCIL MEMBERSHIP APPLICATION
4. First Name*
5. Last Name*
6. Email Address*
8. Address
10. City*
11. State*
12. Zip Code*
14. Phone Number*
16. Employment History:
18. Present Employer:
20. From:
21. To:
23. Previous Employer:
25. From:
26. To:
28. Educational Background:
30. High School:
31. Certificate / Diploma/ Degree
33. If you have not received a high school diploma or GED, please explain why (optional):
35. College:
36. Certificate / Diploma / Degree
38. Other:
39. Certificate / Diploma / Degree
41. Community Related Activities:
43. Please list:
45. SERVICE
47. Please list current and past position(s) held on City / County Boards, Committees, and/or Commissions:
49. Board or Commission
50. Years of Service (From - To)
52. Board or Commission
53. Years of Service (From - To)
55. Why do you feel you would be a valuable member of the Spokane Regional Law and Justice Council? Please list specific experience/education/qualifications or insight you may have to bring to the Spokane Regional Law and Justice Council.*
57. How will you engage and inform other Spokane County citizens as their public representative on this committee?*
59. UNDER THE PUBLIC DISCLOSURE ACT, ALL INFORMATION IN THIS APPLICATION IS SUBJECT TO DISCLOSURE UPON REQUEST EXCEPT THE FOLLOWING INFORMATION IS NOT SUBJECT TO DISCLOSURE: RESIDENTIAL ADDRESSES, RESIDENTIAL TELEPHONE NUMBER, PERSONAL WIRELESS TELEPHONE NUMBERS, AND PERSONAL ELECTRONIC MAIL ADDRESSES.
61. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
63. Electronic Signature*
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field