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2. I acknowledge that all information submitted in this application becomes a public record and will be searchable online. The Village is not able to remove information from the public record once it has been posted.

   1. I Agree
4. First Name & Middle Initial
5. Last Name
7. Address
9. City
10. State
11. Zip Code
13. Email Address
14. Primary Phone
15. Alternate Phone
17. Residency within the municipal boundaries is required for membership on most Village advisory bodies. How long have you lived in the Village of Clemmons?

    1. 0 to 12 Months
    2. 1 to 3 Years

    1. 4 to 9 Years
    2. Greater Than 10 Years
19. The Council encourages you to visit a meeting of the group that you are interested in serving on. Please choose no more than two groups from the following list to which you would like to apply.
21. Which Board is your first choice?

    1. Planning Board
    2. Zoning Board of Adjustment
    3. Triad Municipal ABC Board
22. Which boards would you like to apply for? You may select up to 2.

    1. Planning Board
    2. Zoning Board of Adjustment
    3. Triad Municipal ABC Board
24. How did you find out about this opportunity?

    Select All That Apply

    1. Advisory Board or Council Member
    2. Email
    3. Facebook/Nextdoor/LinkedIn
    4. Newspaper
    5. Speaker at an Event
    6. Website
    7. Other
25. Please Name
27. If you are not chosen for this board, are you open to being called upon for a sub-committee or ad hoc board?

    1. Yes

    1. No
29. Interests & Experiences
31. What perspective(s) do you bring to the board(s), committee(s) or task force(s) to which you are applying?
33. Please provide a brief summary of any other relevant qualifications (skills, abilities, interests and/or experience) you bring.
35. Please provide a statement of why you wish to serve. Please be advised that any information submitted becomes a public record and may be searchable online.
37. You May Attach a Supporting Document
41. Ethics Guidelines for Town Advisory Boards & Committees

    Members of advisory boards and committees shall not discuss, advocate, or vote on any matter in which they have a conflict of interest or an interest which reasonably might appear to be in conflict with the concept of fairness in dealing with public business. A conflict of interest or a potential conflict occurs if a member has a separate, private, or monetary interest, either direct or indirect, in any issue or transaction under consideration. In addition, members of the Board of Adjustment, when these boards are hearing cases, serve as quasi-judicial bodies. Pursuant to State Statute 106A-388(e)(2), members of these boards “shall not participate in or vote on any quasi-judicial matter in a manner that would violate affected persons’ constitutional rights to an impartial decision maker. Impermissible violations of due process include, but are not limited to, a member having a fixed opinion prior to hearing the matter that is not susceptible to change, undisclosed ex parte communications, a close familial, business, or other associational relationship with an affected person, or a financial interest in the outcome of the matter.”
    
    Any member who violates these Ethics Guidelines may be subject to removal from the board or committee. If the advisory board or committee member believes he/she has a conflict of interest then that member should ask the advisory board or committee to be recused from voting. The advisory board or committee should then vote on the question on whether or not to excuse the member making the request. In cases where the individual member or the advisory board or committee establishes a conflict of interest, then the advisory board or committee member shall remove themselves from the voting area. Any advisory board or committee member may seek the counsel of the Town Attorney on questions regarding the interpretation of these ethics guidelines or other conflict of interest matters.
    
    The interpretation may include a recommendation on whether or not the advisory board or committee member should excuse himself/herself from voting. The advisory board or committee member may request the Town Attorney respond in writing.

    1. I Agree
43. Applications will be kept on file from July 1st to June 30th of the same fiscal year. Please reapply each fiscal year if you are still interested in serving on an Advisory Board, Committee or Task Force and have not yet been appointed.
    You may submit your application or print and return to:
    Village of Clemmons
    3715 Clemmons Road
    Clemmons, NC 27012
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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

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