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Dade County Board of Commissioners
County Clerk's Office -Dade County Administrative Building
71 Case Avenue, Suite 243, P.O. Box 370, Trenton, GA 30752-0613
(706) 657-4625
Board Position Applied For:
1. 1) Alcohol Beverage Control Board (ABC)
2. 2) Board of Assessors
3. 3) Development Authority
4. 4) Division of Family & Children Services Board (DFCS)
5. 5) Board of Education
6. 6) Board of Elections
7. 7) Board of Health
8. 8) Historic Preservation Commission
9. 9) Industrial Development Authority
10. 10) NWG Development Authority (Northwest Georgia)
11. 11) Library Board
12. 12) Limestone Valley RC&D (Resource Conservation & Development Council)
13. 13) Lookout Mountain Community Services Board
14. 14) Board of Mental Retardation
15. 15) Special Use Permit Board
16. 16) Water and Sewer Authority
17. 17) Trenton Dade Animal Center Advisory Board
BOARD APPOINTMENT APPLICATION
Thank you for your interest in publicly serving with Dade County. Please complete and return to the County Clerk’s Office at 71 Case Ave Trenton, GA 30752. Call 706-657-4625 with any questions.
PERSONAL DATA
Last Name
First Name
Middle Name
Home Address (Street)
City
State / Zip
Personal Email Address:
Telephone (Business)
Telephone (Residence)
Cell Phone
Best Call Back Number
Times Available at phone
Residency District
How Long?
EMPLOYER DATA
Employer:
Occupation:
Work Number:
Work Email:
BOARD INFO
Have you ever been a board member before?
1. Yes
2. No
If yes, when are which board?
Are you currently on any other City or County Board?
1. Yes
2. No
If so, which board are you currently a member of?
Is this a new appointment?
1. Yes
2. No
If a Re-appointment, when does your term expire?
Do you agree to abide by the attendance policy of the Board, Commission, Authority, or Advisory Committee to which you are applying?
1. Yes
2. No
In the event, that the Board, Commission, Authority, or Advisory Committee does not have an attendance policy, do you agree to abide by the attendance policy listed below?
1. Yes
2. No
ATTENDANCE POLICY:
IF ANY MEMBER FAILS TO ATTEND TWO (2) OF THREE (3) SUCCESSIVE MEETINGS WITHOUT CAUSE AND PRIOR APPROVAL FROM THE CHAIRPERSON, THE BOARD, COMMISSION, AUTHORITY, OR ADVISORY COMMITTEE SHALL DECLARE THE MEMBER’S SEAT VACANT, AND THE COUNTY COMMISSIONERS SHALL PROMPTLY APPOINT A REPLACEMENT.
I understand that upon selection as a Board/Committee member that I may be required to authorize and submit a background check application at no cost to me.
1. Yes
2. No
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Step Two

BACKGROUND INFORMATION
Have you been convicted of a criminal offense against the law within the last ten (10) years or are you now under charges for any offense against the law, either a felony or a misdemeanor?
1. Yes
2. No
If Yes, Give Complete Details Below:
Charge
Date
Date
Location
Disposition
***
Please be advised that a prior conviction does not automatically disqualify an individual from appointment. Each conviction will be assessed on a case-by-case basis, considering the time elapsed, the specific circumstances surrounding the conviction, and its severity in relation to the position being applied for.
There shall be no discrimination against an otherwise qualified volunteer by reason of disability, age, race, color, ethnicity, sex, creed, national origin, citizenship or socioeconomic status.
By signing below, I verify that the information provided on this application is true and correct and I agree to serve if appointed:
ACKNOWLEDGMENT & SIGNATURE
Read, acknowledged and consented to on this date:
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.
Electronic Signature
Date / Time
Date / Time
Date / Time
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Step Three

BOARDS / COMMISSIONES / AUTHORITIES / COMMITTEESS FOR DADE COUNTY, GEORGIA
1) ABC Board
2) Board of Assessors
3) Development Authority
4) Board of DFCS
5) Board of Education
6) Board of Elections
7) Board of Health
8) Historic Preservation Commission
9) Industrial Development Authority
10) NWG Development Authority
11) Library Board
12) Limestone Valley RC&D
13) Lookout Mtn. Community Services Board
14) Board of Mental Retardation
15) Special Use Permit Board
16) Water and Sewer Authority
17) Trenton Dade Animal Center Advisory Board

Leave This Blank:

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

This field is not part of the form submission.
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