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Untitled Document

Alexandria Complete Count Committee for 2020 U.S. Census Application

Please complete this form in its entirety. The deadline for submission has been extended to 5 p.m. on Sunday, November 25. Any questions may be directed to Sierra Latham, Department of Planning and Zoning, sierra.latham@alexandriava.gov or 703-746-3832. Further detail can be found at alexandriava.gov/Census2020.

Contact Information

Date: This question requires a valid date format of MM/DD/YYYY.

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Name:

Home Address:

Phone:

Email: This question requires a valid email address.

Date of Birth: This question requires a valid date format of MM/DD/YYYY.

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Do you live or work in the City of Alexandria?

1. Which type of organization will you be representing?

2. If applicable, what is the name of the organization you are representing?

3. Please explain why you would like to serve on the Complete Count Committee:

4. Provide any information about your experience relevant to this effort:

5. Which languages do you speak? Please select all that apply.

5.a. Please list any other language you speak:

6. Attach a resume or any relevant documents.

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7. Are you now paid by the City of Alexandria? If yes, please state your department, job title and describe your duties:

8. Do any of your immediate relatives or business associates serve the City of Alexandria in any capacity? If yes, please explain:

9. Are you currently a member of a City Board, Commission, Committee or Authority? If yes, please list the City Board, Commission, Committee or Authority:

10. References: (Please list name, addresses and contact information of three references that support your application)

Space Cell	Name	Address	Contact Information
1.	1.: Name	1.: Address	1.: Contact Information
2.	2.: Name	2.: Address	2.: Contact Information
3.	3.: Name	3.: Address	3.: Contact Information

11. Attendance Requirements: Sec. 2-4-7 of the City Code requires appointees to attend at least 75% of the yearly committee meetings. Absences may be excused because of personal illness or serious illness of members of the immediate family, death of a family member, unscheduled or unforeseen business trips, and emergency work assignments only. All other absences are recorded as unexcused.

In light of the above, will you be able to attend at least 75 percent of the regular meetings of the board which you may be appointed?

12. If applicable, will you comply with the provisions of the City's conflict of interest requirements in City Ordinance 2867?

Note: Selecting the 'Next' button below completes the application.