Name: |
|
This profile is NEW |
OR |
Updated: |
Address, City, State, ZIP: |
|
County: |
|
Email Address: |
|
Employer: |
|
Business Address: |
|
|
|
Home Phone: |
|
Office Phone: |
|
Fax Number: |
|
|
|
Occupation: |
|
|
|
Registered to Vote at Home Address (please check yes or no) |
Yes OR No
|
Date of Birth: |
|
Gender: |
Female OR Male |
Race |
White (Not of Hispanic origin). All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black or African-American (Not of Hispanic origin). All persons having origins in any of the Black racial groups of Africa.
Hispanic or Latino. All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander. All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.
American Indian or Alaskan Native. All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
|
Missouri Resident Since (year) |
|
Congressional District |
|
State Representative District |
Find your legislator. |
State Senate District |
|
School District |
|
Political Party Affiliation |
|
|
|
List any immediate family members who are current government employees or who receive a significant amount of their income through government contracts: |
Relation |
Employer |
Indicate position & dates of service, if you served on a public board, commission or in public office (city, state or elective office) |
|
|
|
Indicate Public Policy Interest: (1) Strong (2) Moderate (3) No Interest
|
To assure that public boards and commissions are representative of the population, please state what experience or qualities you possess that would help attain that goal: |
|
List any additional information about yourself you think would be helpful: |
|
Are you interested in full time public employment? |
Yes OR No |
Are you willing to relocate? |
Yes OR No |
Resume attached? |
Yes OR No |
|
|
Educational Background |
|
|
|
Employment History |
|
|
|
List Community Activities |
|
|
|
List Professional Activities |
|
|
|
List Organizational Affiliations |
|
|
|
|
|
|