City of Jacksonville

Commission
Institute for Effective Change Application
Applicant Information

Full Name: Date:

Last First M.I.

Address:
Street Address Apartment/Unit #

City State ZIP Code

Phone: Email

Position Applied for

(Member,
Commission Co-
Chair, DOA Liaison,
DCA Liaison,
Operating Chair):

YES NO YES NO
Are you a citizen of the United States? If no, are you authorized to work in the U.S.?

YES NO
Have you ever been convicted of a felony?

If yes, explain:

Education

School/College: Address:

From: To:

References
Please list one professional reference.

Full Name: Relationship:

Email: Phone:

Essay Questions
All responses should not be more than 300 Words.

Why are you applying to join the Institute for Effective

Change?

1
What do you believe is the mission of the Institute for
Effective Change?

What do you bring to the team, that no one else

possesses? (such as leadership, specific character etc.)

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to selection, I understand that false or misleading information in my application or
interview may result in my release.

Signature: Date:

-Interested Parties wishing to charter a commission should direct inquires to 4effectivechange@gmail.com