EMS Advisory Committee Application

Required fields are marked with an asterisk (*).

1. Full Name*
2. Phone*
3. Home Address*
4. Email*
5. City*
6. ZIP*
7. Years Residing in Jasper County*
8. Relevant Background or Experience (check all that apply)

   Medical/Healthcare
   Finance/Accounting
   Business
   Public Administration
   Farming
   Other
9. If Other, please specify
10. 1. Why are you interested in serving on the Jasper County EMS Advisory Committee?*
11. 2. What experience, skills, or perspective would you bring to the committee?*
12. 3. List any current or previous employment, volunteer service, board membership, or affiliation with an EMS, fire, healthcare, municipal, township, or county organization.*
13. Are you generally available to attend scheduled committee meetings?*

    Yes
    No
    Depends on meeting schedule
14. Certification and Acknowledgment*

    I certify that the information provided is accurate. I understand that this is an advisory, unpaid public-service position; regular attendance and open, objective participation are expected; the Board of Supervisors makes the final appointment; and information submitted may be subject to disclosure under Iowa law.
15. Signature of Applicant*
16. Date
17. reCAPTCHA