Participating in a community board is a critical way for residents of New York City to engage with and influence their local government and community decisions. At the heart of this participation is the Community Board Application form, which signifies the beginning of the journey for potential new members. This document, outlined by the office of the Brooklyn Borough President, Eric L. Adams, outlines a thorough process involving personal, employment, and community-related information to ensure that applicants are well-qualified for the roles they wish to take on. Applicants are required to accurately fill out contact details, employment history, including any potential conflicts of interests, and their community involvement. This detailed application also allows candidates to state why they believe they would be effective community board members, contributing to the board's array of committees, with the freedom to express their special interest in specific neighborhoods. An emphasis is placed on the need for this application to be notarized, demonstrating the seriousness with which the information is regarded. Furthermore, the collection of this data under the specter of the Freedom of Information Law underscores the transparency and openness in the selection process. Lastly, the form is sensitive to the need for inclusive and diverse board compositions, optionally inviting applicants to share demographic information to help achieve this goal.
| Question | Answer |
|---|---|
| Form Name | Community Board Application Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | 2018 community board application form, community board application, community board 12 application, brooklyn borough president community |
ERIC L. ADAMS
PRESIDENT OF THE BOROUGH OF BROOKLYN 209 Joralemon Street
Brooklyn, NY 11201 (718)
Office Use Only
Council District #
Date Received
Date Input
NEW MEMBERSHIP APPLICATION FOR
COMMUNITY BOARD NO. ____
NOTE TO APPLICANTS: You must be a New York City resident to serve on a community board. To qualify for a particular board, you must live, work in, or have a professional or other significant interest in that board’s district.
THIS APPLICATION MUST BE NOTARIZED AND RETURNED BY MAIL. DO NOT FAX OR EMAIL.
Please type or print clearly in ink. Do not leave any areas blank. If questions do not apply, indicate “n/a” or draw a slash
through the section.
The Freedom of Information (FOI) law may allow for public review of this application upon request.
CONTACT INFORMATION
Mr.
Ms.
Mrs.
Dr.
Other _________________________
NAME: __________________________________________________________________________________
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(Last) |
HOME ADDRESS (INCLUDE APT. NO.) ________________________________________________________ |
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CITY ______________________________________________ STATE __________ |
ZIP ______________ |
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PHONE: |
Home |
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Mobile ( |
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Work |
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Fax |
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EMAIL: __________________________________________________________________________________
EMPLOYMENT INFORMATION
EMPLOYER _______________________________________________________________________________________
YOUR TITLE/POSITION _____________________________________________________________________________
EMPLOYER ADDRESS ___________________________________ |
CITY __________ ST ______ ZIP ___________ |
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TELEPHONE ( |
) __________________________________ |
YEARS WITH EMPLOYER _______________ |
NOTE TO APPLICANTS: Conflicts of Interest Board rulings require that applicants disclose whether they or their employers derive any income representing clients before the community board (i.e. attorneys, architects, consultants, etc.). These rulings do not automatically exclude one from board membership, but the information is essential.
Brooklyn Borough President’s Office Community Board Application 2015 |
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COMMUNITY ACTIVITIES
LIST ALL CIVIC AND COMMUNITY ORGANIZATIONS, NEIGHBORHOOD ASSOCIATIONS AND/OR ANY OTHER
GROUPS. (Please indicate if you hold any executive positions, including board of directors.)
ORGANIZATION |
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DATES |
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TITLES |
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ADDRESS |
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PLEASE STATE WHY YOU BELIEVE YOU WOULD BE AN EFFECTIVE COMMUNITY BOARD MEMBER AND PROVIDE ANY ADDITIONAL INFORMATION YOU BELIEVE WOULD BE USEFUL IN CONSIDERING YOUR APPLICATION. (A
resume or current biography is required. Attach to this application.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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COMMUNITY INTEREST (check all that apply)
LIVE IN DISTRICT □ |
*WORK IN DISTRICT □ |
*PROFESSIONAL/SIGNIFICANT INTEREST □ |
*Please describe: ________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
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NEIGHBORHOOD OF INTEREST _____________________________________________________________
HAVE YOU ATTENDED A MEETING OF THIS COMMUNITY BOARD IN THE PAST YEAR? YES □ NO □
ARE YOU CURRENTLY SERVING (or have you previously served) AS A MEMBER OF A COMMITTEE OF |
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THIS COMMUNITY BOARD? YES □ NO □ If so, please list committee(s) _________________________________________ |
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HOW MANY HOURS PER MONTH CAN YOU DEVOTE TO COMMUNITY BOARD ACTIVITIES? _______ |
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HAVE YOU EVER SERVED ON A COMMUNITY BOARD? YES □ |
NO □ |
If yes, complete the information requested below. Please note if you were a public member of a board committee.
CB No. |
COUNTY |
DATES SERVED |
POSITION HELD |
COMMITTEE |
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______________________ |
______________________ |
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PLEASE NOTE: AS A COMMUNITY BOARD MEMBER, YOU MAY BE EXPECTED TO SERVE ON 2 OR MORE COMMITTEES.
Brooklyn Borough President’s Office Community Board Application 2015 |
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REFERENCES |
NAME _______________________________________ |
ADDRESS _____________________________________________________ |
TELEPHONE (_____) ______________________ |
AFFILIATION/RELATIONSHIP ____________________________________ |
NAME _______________________________________ |
ADDRESS _____________________________________________________ |
TELEPHONE (_____) _______________________ |
AFFILIATION/RELATIONSHIP ____________________________________ |
NAME _______________________________________ |
ADDRESS _____________________________________________________ |
TELEPHONE (_____) _______________________ |
AFFILIATION/RELATIONSHIP _____________________________________ |
IDENTIFICATION AND STATEMENT
I (check one) □ HAVE NEVER □ HAVE been convicted of a misdemeanor or felony. (If you have, describe and
explain on a separate sheet of paper and attach it to this application.)
I am not employed by a Council Member whose district covers parts of this community board district, or by the Brooklyn Borough President. I am not employed by the State or City of New York in a position at or above the level of Assistant Commissioner or have secured a mayoral waiver allowing me to serve on a community board and have affixed a copy hereto.
I affirm that I am a New York City resident and that I am at least 16 years of age.
I HEREBY AFFIRM THAT ALL THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
PRINT NAME ___________________________________ |
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SIGNATURE ____________________________________ |
DATE _________________________ |
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Sworn to before me this _______ day of ____________, 20_____ |
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NOTARY PUBLIC or |
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COMMISSIONER |
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OF DEEDS |
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Brooklyn Borough President’s Office Community Board Application |
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The following sections are optional
The following information is requested to help ensure that community board composition adequately reflects the demographics of the area served. You are not required to answer these questions, but your response will help us ensure diverse and inclusive community boards.
Month of Birth: _______________________________ |
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Age Range: |
□ Under 18 |
□ 65+ |
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Which of these best describes your gender? |
□Other |
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□ Female |
□ Male |
□Transgender |
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Which of the following best describes how you identify? You may check multiple boxes.
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African American/Black
Caribbean/West Indian
Latino(a)/Hispanic
South Asian
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Asian American/Pacific Islander
Caucasian/White
Native American/American Indian
Other
Do you have any disabilities? If yes, what type of disability?
_________________________________________________________________________________
Is there anything else you would like our office to know about how you
_________________________________________________________________________________
If appointed, in which of the following substantive areas of activity would you prefer to be involved? (Order preferences with 1 being the highest)?
_____ Housing |
_____ Planning & Zoning |
_____ Education |
_____ Transportation |
_____ Health & Hospital |
_____ Finance & Budget |
_____ Sanitation |
_____ Parks & Recreation |
_____ Public Safety |
_____ Arts & Culture |
_____ Senior Citizen Affairs |
_____ Environment & Ecology |
_____ Consumer Affairs |
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_____ Other (please specify):
Brooklyn Borough President’s Office Community Board Application |
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