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CITY OF IOWA CITY Application Form
UNESCO CITY OF LITERATURE
This application is a public document and as such can be reproduced and distributed for the
public. This application will be considered for twelve months only and automatically
considered for any vacancy during that time.
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Advisory Board/Commission/Comm� tee Name t'� � (��� �,o,� ��r�,�',�
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Date of Application �
Name �-}v'��7,t,y}n �
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Home Address �r L., � �, •
Contact phone number , � — �� + � (J�'�Email A dress �6� �,�_�� ;,��� (; ���
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Your home address must be within the corporate limits of Iowa City?
How long have you lived in Iowa City? �[,� � A �
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Occupation: V'�' �1�,��
Gender: Male� Female
Experiences and/or activities . hich you feel qualify you for this position:
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What is your present knowledge of this advisory board? A ,
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Please contact the city attorney at 319-356-5030 to discuss questions or concerns regarding a
potential conflict of interest.
Potential Conflict of Interest
The Housing and Community Development Commission makes recommendations to the City
Council regarding the distribution of federal CBDG/HOME funds. The general rule is that no
persons who exercise or have exercised any functions or responsibilities with respect to federally
funded activities, or who are in a position to participate in the decision—making process or gain
inside information with regard to such activities, may obtain a financial interest or benefit from a
federally-assisted activity, ar have a financial interest in any contract, subcontract, agreement with
respect to the proceeds of the federally—assisted activity, either for themselves or those with whom
they have business or immediate family ties, during their tenure ar for one year thereafter.
Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a
member of a city Board or Commission from having an interest in a city contract. Section 362.5
City Council Resolution #15-300 established a policy that the following persons shaTl not be
eligible for appointments to Boards and Commissions. � °� �
A council member's spouse, domestic partner or partner in cohabitation, children,.step childre�, �
children for whom the Council Member assumes parental responsibility, mother, father; son-in-law,„ ;,
daughter-in-law, sister-in-law, grandparents, and grandchildren, aunt, uncle, niece, pephew, first �.
cousin, foster parent,poster child,persons who are parents of the same child, and persons whom the '�
employee is in an intimate relationship.
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Res. #15-300 states that each application for reappointment to a City Board or Commission will be
considered without regard to incumbency. If reappointed, an individual would be limited to one
reappointment to a full term in order to increase the opportunities for new applicants to serve.
Council policy is not to permit an individual to serve on two Boards or Commissions at the same
time. You will be asked to resign from one if appointed to another.
Do you currently have a conflict of interest?YES NO
List potential conflicts of interest(See last page for information regarding conflict of interest)
Please indicate if there are none.
BUSINESS NAME BUSINESS ADDRESS
Do you currently serve on another Iowa City board or commission?YES NO
If so which one do you prefer?
The City Council values all types of diversity on its boards and commissions. Your responses on
this page provide valuable information to the Council in achieving that goal.
In order to ensure that the board and commission is representative of the community and the
groups(s)which it serves,please provide your information for the following:
Age�
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Country of Origin �, � � ..P/In��
SexualOrientation ,�,`c,�
Religion �4��, �,,�
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Do you have a disability?YES � NO ��y��L� � �j�/� l �
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Race, Color or Ethnic Group
*Note:
The Human Rights Commission strives to ensure the Commission is representative of the
community. Therefore appointment shall take into consideration persons of various racial,
religious, cultural, social and economic groups in the city. (Ordinance)
The Housing and Community Deve pment Commission strives to satisfy its purpose and
intent, when possible to �a�e- st`�one person w th expertise in construction, at least one
person with expertise finance an one p n ho ,�ceives ental assistance. (Resolution)
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Signature of Applicant*�..-.---
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Misrepresentations on this application will constitute just cause for removal of an appointee.
If you fail to answer all the questions, Council will not consider your application.
You are encouraged to contact individual Council Members to express your interest in
serving. Contact information is attached.
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