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2. Name*
4. Address (Home)
6. Address ( Work)
8. Email
10. Phone (Cell)*
11. Phone (Work)
13. Gender

    1. Female
    2. Male
15. Profession (Job Title)
17. Ward of the city in which you reside:
19. Specific city board/commission of interest
21. Leadership Okmulgee Program Graduate

    1. Yes
    2. No
23. Please attach resume or qualifications
25. Upload
    Please attach resume or qualifications.
27. 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.

    1. I agree.
29. Electronic Signature
31. Note
    Applications will be purged after two years. Please consider reapplying at that time if you remain interested in serving on a Board and have not yet been appointed.
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field