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21.316 Whiting Street Fund Commissioner ReappointmentsForm Center ►� City of Northampton, Massachusetts By signing in or creating an account, some fields will auto -populate with your information and your submitted forms will be saved and accessible to you. Application for Appointment to Boards, Committees and Commissions City of Northampton Application for Appointment to Boards, Committees, and Commissions Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060 First Name* A Last Name* Title, if applicable Address1* Address2 City* aNC� State* Zip* Home Phone N Work Phone ` � f Cell Phone Occupation & Place of Employment Email Are you a Northampton resident? 9-1�e_s ❑ No Years Lived in Northampton & LL "y LA Age This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so. ❑ Under 29 ❑ 50 - 59 ❑ 30 - 39 ❑ 60 - 69 ❑ 40 - 49 �Oplus Sex This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so. late ❑ Non -Binary ❑ Female Racial / Ethnic Background C "/ tO This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so. Date* mm/dd/yyyy I protected by reCAPTCHA Privacy ;ernes 0 Receive an email copy of this form. Email address c 14- k- ,A c&mc/UT . Nt 7-- This field is not part of the form submission. * indicates a required field Boards and Committees Please indicate the boards and committees you have an interest serving on. ❑ Agricultural Commisssion ❑ Municipal Affordable Housing Trust Fund Board ❑ Arts Council of Trustees ❑ Assessors, Board of ❑ Central Business Architecture Committee ❑ Community Preservation Committee ❑ Conservation Commission ❑ Council on Aging ❑ Disability Commission ❑ Energy & Sustainability Commission ❑ Health, Board of ❑ Historical Commission ❑ Housing Partnership ❑ Human Rights Commission ❑ License Commission Please list 'other" board or committee of interest ❑ Northampton Housing Authority- Board of Commissioners ❑ Parks and Recreation Commission ❑ Planning Board ❑ Public Shade Tree Commission ❑ Redevelopment Authority Q Registrars, Board of ❑ Special Charter Review Committee (Ch. 9 of the Code of Ordinances) ❑ Transportation & Parking Commission ❑ Trust Fund Committee Whiting Street Fund Committee ❑ Youth Commission ❑ Zoning Board of Appeals What skills and experience will you bring to this committee assignment?* tAJ O I t-1 t'�16 5ITtl r T 'PD P 60-M M 1 AT--b /L- 40 + N �-f►}` Are you currently serving or have you served on any city committee?* ❑ No 21�res Please list other city committees you have served on ik rvr N6 FIQK�9 62-� I, Required: Please read the following, by signing below you state that you understand and agree. The filing of this form does not guarantee my appointment. An application is kept on file for two (2) years; after that I must file a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conflict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conflict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form. Signature* City of Northampton Application for Appointment to Boards, Committees and Commissions Name: Joseph P. Misterka Address: 312 Chesterfield Road Email: josephmisterka@yahoo.com Home Phone: 413.586.0432 Work: Cell: Occupation: Retired: Northampton School Department Years lived in Northampton: lW Please indicate the Committee(s) you have interest serving on: (Appointment subject to vacancies) Affordable Housing Trust Historical Commission Agricultural Commission lHousing Partnership -Fair Housing Arts Council Human Rights Commission Board of Health License Commission Board of Public Works Northampton Housing Authority Cable Advisory Board Planning Board Capital Improvements Recreation Commission Central Business Architecture Registrar of Voters Conservation Committee Transportation & Parking Commission Committee on Disabilities Bicycle and Pedestrian Subcommittee Community Preservation Committee iTree Committee Council on Aging IYouth Commission Elm Street Historic District Zoning Board of Appeal Energy Resources Commission I 10ther Oaof: cS What skills and experience will you bring to this Committee assignment: (attach additional sheet or resume if necessary) I believe That my experiences in the School Department have helped me have empathy for who are struggling financially, i.e. Free and Reduced Lunch Program, Althetic and Transportation Fees. In this capacity, I have shown fairness and confidentiality with the sensitive nature of personal financial information. Thank you for your consideration for this appointment. Are you currently serving or have you served on any City committee: _� No _ ✓Q Yes* (*If yes please state what committee) Board of Almoners Required: Please read the following, by signing below you state that you understand and agree: The filing of this form does not guarantee my appointment. An application is kept on file for two (2) years; after that I must file a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conflict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conflict of interest test AFTER being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. IMPORTANT. Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form! (ce, oy. I.aAL� SIGNATURE DATE Please Return Form To: Mayor@northamptonma.eov or David J. Narkewicz, Mayor, 210 Main Street, Northampton, MA 01060 This information will be used for diversity purposes only. Complete it only if you wish to do so. Age: Under 29 30-39 40-49 50-59 60-69 70 plus ✓ Sex: M ✓ F Non -Binary Racial/Ethnic Background Please Return Form To: or David J. Narkewicz, Mayor, 210 Main Street, Northampton, MA 01060 City of Northampton Application for Appointment to Boards, Committees and Commissions Name: UL .t !- 'Ll f OL LL Address 1,9 Email: Home Phone:- ' Work: Cell: Occupation: Cox Years lived in Northampton: Northampton Resident: Yes No Please indicate the Committee(s) you have interest serving on: (Appointment sub feet to vacancies) Agricultural Commission License Commission Almoners, Board of Municipal Affordable Housing Trust Fund Board of Trustees Arts Council Northampton Housing Authority- Board of Commissioners Assessors, Board of Planning Board Central Business Architecture Committee Public Shade Tree Commission Community Preservation Committee Public Works Commission Conservation Commission Redevelopment Authority Council on Aging Registrars, Board of Disability Commission Transportation & Parking Commission Energy & Sustainability Commission Trust Fund Committee Health, Board of Youth Commission Historical Commission Zoning Board of Appeals Housing Partnership Human Rights Commission What skills and experience will you bring to this committee or board assignment? (attach a#itional sheet of resume if necessary) % / j I r". , I. Are you currently serving or have (*Ifyes, please state the committee or board Required: Please read the following, by signing below you state that you understand and agree: The filing of this form does not guarantee my appointment. An application is kept on file for two (2) years; after that I must file a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conflict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conflict of interest test AFTER being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. IMPORTANT. • Once this form is submitted, it becomes a public document, if there is information you do not want open to the public please do not include it on this form! SIGNATURE 4tl� �_7bhAlv DATE d �( Please Return Form To: mayor(cDnorthamptonma gov or David J. Narkewicz, Mayor, 210 Main Street, Northampton, MA 01060 Name: Address: Email: �( Home Phone: City of Northampton Application for Appointment to Poards, Committees and Commissions ei�;Ibf /3 2�/L 6- L Work: C Cell: /r , % JAY Occupation: Ar V 101 PA e&l Years lived in Northampton: Northampton Resident: es No Please indicate the Committee(s) you have interest serving on: (appointment subject to vacancies) Agricultural Commission License Commission Almoners, Board of Municipal Affordable Housing Trust Fund Board of Trustees Arts Council Parks and Recreation Commission Assessors, Board of Planning Board Central Business Architecture Committee Public Shade Tree Commission Community Preservation Committee Public Works Commission Conservation Commission Redevelopment Authority Council on Aging Registrars, Board of Disability Commission Transportation & Parking Commission Energy & Sustainability Commission Trust Fund Committee Health, Board of Youth Commission Historical Commission Zoning Board of Appeals Housing Partnership Human Rights Commission What skills and experience will you bring to this Committee assignment: (attach add tional sheet or resume if necessary) Are you currently serving or have you (*Ifyes please state what committee) on any City committee: No (/ Yes* Required: Please read the following, by signing below you state that you understand and agree: The filing of this form does not guarantee my appointment. An application is kept on file for two (2) years; after that I must file a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conflict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39; Section 23B. I understand that I will take the conflict of interest test AFTER being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. IMPORTANT: Once this fora, is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this farm! SIGNATURE DATE Please Return Form To: Mayor@northamptonma.eov or David J. Narkewicz, Mayor, 210 Main Street, Northampton, MA 01060