Form Center

2. Please complete the online form below.
4. First Choice: Select the Board, Commission, or Committee applying for:*
   -- Select One --Airport CommissionBoard of Zoning AppealsBuilding Code Board of AppealsCommission of Architectural ReviewCommunity Improvement CouncilDan River Alcohol Safety Action ProgramDCC Board of TrusteesDanville Development CouncilDanville Redevelopment and Housing AuthorityDanville Utility CommissionDanville Community Policy & Managment TeamDP Community Services BoardEmployee's Retirement System BoardFair Housing BoardIndustrial Development AuthorityIALR Board of DirectorsMemorial CommissionPlanning CommissionRiver District Design Commission* Roanoke River Basin AssociationSocial Services Advisory BoardSouthern Area Agency on AgingTransportation Advisory BoardWest Piedmont Planning District Commission
6. Second Choice: Select the Board, Commission, or Committee applying for:
   -- Select One --Airport CommissionBoard of Zoning AppealsBuilding Code of AppealsCommission on Architectual ReviewCommunity Improvement CouncilDR Alcohol Safety Action ProgramDanville Development CouncilDanville Redevelopment & Housing AuthorityDanville Utility CommissionDCC Board of TrusteesDanville Community Policy & Managment TeamDP Community Services BoardEmployee's Retirement SystemFair Housing BoardIALR Board of DirectorsIndustrial Development AuthorityMemorial CommissionPlanning CommissionRiver District Design Commission* Roanoke River BasinSocial Services Advisory BoardSouthern Area Agency on AgingTransportation Advisory CommissionWest Piedmont Planning District Commission
8. Third Choice: Select the Board, Commission, or Committee applying for:
   -- Select One --Airport CommissionBoard of Zoning AppealsBuilding Code AppealsCommission on Architectural ReviewCommunity Improvement CouncilDR Alcohol Safety Action ProgramDanville Development CouncilDanville Redevelopment & Housing AuthorityDanville Utility CommissionDCC Board of TrusteesDanville Community Policy & Managment TeamDP Community Services BoardEmployee's Retirement System BoardFair Housing BoardIALR Board of DirectorsIndustrial Development AuthorityMemorial CommissionPlanning CommissionRiver District Design Commission* Roanoke River BasinSocial Services Advisory BoardSouthern Area Agency on AgingTransportation Advisory CommissionWest Piedmont Planning District Commission
10. Personal Information
12. Name:*
14. Maiden Name:
16. Street Address:*
18. City*
19. State*
20. Zip*
22. Home Phone Number:*
24. Email Address:
26. Date of Birth:*
27. Place of Birth:
29. *Some Boards or Commissions do not require city residency, but may require business involvement within the City of Danville. If this is applicable, please be sure to fill out the following business questions.
31. Business Name and Address:
33. Business Phone Number:
35. Occupation:
37. Length of Residency in Danville:*
39. Are you a registered voter:*

    1. Yes
    2. No
41. Education
43. High School:
45. College:
47. Trade or Business School:
49. Civic Activities
51. Please list organization memberships and positions held:
53. Are you currently serving on other City of Danville Boards, Commissions, or Committees?*

    1. Yes
    2. No
55. If yes, which:
57. Have you served on a Board, Commission, or Committee before?*

    1. Yes
    2. No
59. If yes, which:
61. Do you have a valid Virginia driver's license?*

    1. Yes
    2. No
63. If no, please explain.
65. Are your accounts current with the City (Taxes, Utilities, etc.?) *

    1. Yes
    2. No
67. If no, please explain.
69. References
71. Persons who are not relatives. List name, address and phone number(s).
73. 1.*
75. 2.*
77. 3.*
79. 
    
81. Additional Information (Time available, interests, unique qualifications, etc.)
83. Criminal Record and Child Protective Services Information
85. (Provide information regarding the nature of the convictions and approximate date(s) of "Yes" answers.
87. 1. Except for minor traffic violations, have you been convicted of any violation of law?*
89. 2. Have you ever been convicted of a felony?*
91. 3. Have you ever been convicted of a misdemeanor involving moral turpitude (any offense involving lying, stealing, or cheating) since your 18th birthday?*
93. 4. Are there any criminal charges or proceedings pending against you?*
95. I hereby certify that the information provided on this application is correct to the best of my knowledge and belief. I also hereby authorize the officials of the Central Criminal Records Exchange, and law enforcement officials or officers, the Commissioner of the Department of Motor Vehicles, or any officer or employee of the Department of Motor Vehicles, the Commissioner of the Revenue of the City of Danville, Virginia, The Treasurer of the City of Danville, Virginia, the Director of Central Collections for the City of Danville, Virginia and/or any other person or official to provide any information relating to my record with respect to convictions for traffic violations or other offenses involving the operation of a motor vehicle, felony, or misdemeanor convictions, if any, and/or taxes assessed against me or my property which are delinquent, if any, to the City Clerk, the Council of the City of Danville, Virginia, and/or to any other person designated by the Council to receive such information.
97. I AM WILLING TO SERVE ON MORE THAN ONE (1) AUTHORITY, BOARD, OR COMMMISSION CONCURRENTLY.

    1. Yes
    2. No
99. NOTE: Successful candidates for the Board of Zoning Appeals, Planning Commission, Utility Commission, IDA, and the Housing Authority are required by State Law to complete a Conflict of Interest Form as a condition of taking office and thereafter annually on January 15.
101. Danville City Code Section 2-45(a) "Any person appointed by Council to a board or commission who fails to attend seventy-five(75) percent of the regular meetings of said board or commission will be deemed to have resigned from that office."
103. CONTACT THE CITY CLERK'S OFFICE FOR FURTHER INFORMATION:

     TELEPHONE: (434) 797-8928
     FACSIMILE: (434) 799-5041
     E MAIL: sdemasi@danvilleva.gov
105. BY CLICKING "SUBMIT" YOU ARE SENDING AN ELECTRONIC SIGNATURE THAT VERIFIES EVERYTHING IN THIS APPLICATION IS TRUE AND ACCURATE. IF YOU DO NOT WISH TO SUBMIT AN ELECTORNIC SIGNATURE, PLEASE USE THE CANCEL BUTTON TO EXIT THE APPLICATION.
Leave This Blank:


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

     This field is not part of the form submission.

109. Submit

* indicates a required field