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APPLICATION BOARD OF DIRECTORS CRIME STOPPERS OF MESA COUNTY, INC.
CRIME STOPPERS OF MESA COUNTY does not discriminate on the basis of race, color, sex, age or national origin. Please fill out each line completely and accurately.
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Social Security Number
Place of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail
Name of Employer:
Position:
Years employed with current employer:
Supervisor's Name
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone Number

Area CodePhone Number
Years lived in Mesa County (IF LESS THEN 10 YEARS COMPLETE THE FOLLOWING)
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Club or Organization Affiliations:
The board of directors currently meet the second Wednesday of every month at 7:00 am, at the Grand Junction Police Department, 625 Ute Ave. Will this create a conflict with your present schedule?
Will you take an active role in fund raising?
List any applicable work or volunteer experience:
Please state your reason for wanting to be on the board?
What special gifts or talents do you offer as a potential board member
Have you ever been convicted of any criminal offense? (Excluding traffic citations)
If yes, list charges, location, dates and case(s) outcome:
REFERENCES (Please list two personal and one business contact)
Personal Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Years Known
Personal Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Years Known
Business Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Years Known
By submitting this form, I state that I have voluntarily submitted this information and that it is true and accurate to the best of my knowledge. To the best of my ability, I have not made any false or misleading statements. Furthermore, I understand that this information will be reviewed by law enforcement and that they will conduct a background investigation.
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APPLICATION BOARD OF DIRECTORS CRIME STOPPERS OF MESA COUNTY, INC.