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2. Board, Commission, Committee & Special Service District Application & Certification From

   Instructions: Complete and sign this form and return it to Grand County Commission Office, 125 E. Center St., Moab, UT 84532; fax: 435-259-2574; or commission@grandcountyutah.net

4. Board, Commission, Committee or Special Service District*
   -- Select One --Airport Advisory Committee Arches Special Service DistrictBudget Advisory BoardCanyonlands Care Center Special Service DistrictCemetery Maintenance DistrictConservation District Council on AgingEconomic Development Advisory Board Emergency Medical Services SSDHistorical Preservation CommissionLibrary BoardMoab Mosquito Abatement DistrictPlanning CommissionThompson Springs SS Fire District BoardTransportation Special Service DistrictTravel Council Advisory Board, Moab AreaThompson Springs Special Service Water DistrictWeed Control BoardOther:
5. Other:
7. Name:*
9. Mailing Address:*
11. City:*
12. State:*
13. Zip Code:*
15. Day Phone:*
16. Email Address:
18. In what year did you establish your current residency in Grand County?*
    (residency is required for all Boards; some District boards require residency within the District, which may not include Moab City limits; two years’ residency prior to assuming board membership is required for Planning Commission)
19. If not Grand County, which county do you reside in?
    (applicable for Historical Preservation Commission and Housing Authority of Southeastern Utah)
21. Occupation or professional training:
23. List your work experience that is relevant to your application for a position on the Board or Commission for which you are applying:
25. List your non-work experience that is relevant to your application for a position on the Board or Commission for which you are applying:
27. Grand County Resolution 3184 (October 2019) contains the following Board Member requirements:

    • Must be a Grand County resident (unless otherwise noted);

    • Terms shall be for four years, unless a shorter period is required by law, or unless a midterm vacancy is being filled;

    • Board Members shall have the appropriate expertise when required by law;

    • Submit applications to the Council’s Office by the requirements contained in the notice;

    • Agree to abide by the County’s Conflict of Interest Ordinance.

    Additionally, the State Code has the following requirements for Special Service Districts in Grand County:

    • No appointed member of the Board may be a full or part-time employee of the District while serving on the Board;

    • No person employed by a Special Service District as a full-time or part-time employee may serve on the Governing Board of the District;

    • A Board Member may not be compensated separately as a Board Member and as an employee for providing the same service;

    • Each Trustee/Board Member appointed by the County legislative body shall be an elector (registered voter) of the District

29. I have read, and I certify, that all the information on this form is true and correct and I meet the requirements listed above. Furthermore, if appointed, I agree to faithfully attend the meetings and adhere to the State laws, County ordinances, and adopted Bylaws that govern the Board or Commission on which I am appointed to serve. Additionally, I have read the County’s Conflict of Interest Ordinance (No. 593, 2019) and do not have any inherent conflicts in serving on the Board or Commission to which I have applied. I agree to abide by this Ordinance.

31. Applicant Certification*

    1. By checking this box and typing my name below, I am electronically signing my application.

    I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
33. First Name*
34. Middle Initial*
35. Last Name*
37. Date:
    Date:
38. How did you hear about this position?*
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field