Public Service Personal Profile

Name:

This profile is NEW

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

Transportation	1 2 3	Social Services	1 2 3
Environmental Issues	1 2 3	Education	1 2 3
Economic Development/ Planning	1 2 3	Arts & Humanities	1 2 3
Health	1 2 3	Professional Licensing	1 2 3
Children's Issues	1 2 3	Other	1 2 3

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

Submit a resume as an attachment