Boards & Commissions Interest Form - LPC - La Porte County, Indiana

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Secondary Phone

Primary Phone Type*

Home
Work
Mobile

Secondary Phone Type

Home
Work
Mobile

Email Address

Fax

I am interested in serving on the following Board or Commission*

Please briefly describe your special interests and skills:*

Some boards require a specific mix of Republican and Democrat members. Please select one:*

Republican
Democrat

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.

I agree.

Electronic Signature