City of Chesapeake, Virginia

Boards and Commissions Name Bank Application

Please use alphanumeric characters only (A-Z, 0-9). Special characters (such as ! # $ % and commas) are not allowed.

Should you have any questions about Boards and Commissions, call the Office of the City Clerk at 757-382-6151.

Select Board & Commission Preferences

I am interested in serving on one of the following three (3) boards/commissions.
First Preference:
Second Preference:
Third Preference:

As an applicant/member of a Council-appointed Board or Commission, your name, address, and published phone number will be available to the press and public. Information will be kept on file for two years. Public discussion of information contained herein may occur in the meeting at which appointments are considered by the City Council. If you do not wish discussion of any particular information to occur, please include this information in the box below.

Personal Information

Last Name:  First Name:   M.I.: 
Planning Area:
Historical District:
Street Address:
Apartment Number:
City:  State:   Zip Code: 
Telephone(s): (Primary):    (Secondary): 
Please enter ten (10) digits, with no dashes for Primary and Secondary Phone Numbers
Company/Organization Name:
E-Mail Address*:

Education, Experience, and Community Involvement

Volunteer and/or Community Involvement:

Additional Information

What do you feel you can contribute to the community that may not be evident from information already
on this form?

Previous Service

Have you served on one of our Boards and Commissions previously? If so, please indicate the name and year.

Submit Application

Please ensure you have a valid email address listed in the "Email Address" field.

By clicking on the "Submit" button, you certify that the above information is valid as of date of submission.