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Events
Initiatives
Resources
According to Jim
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Contact/Report
Budget
APPLICATION FOR STATEN ISLAND COMMUNITY BOARD MEMBERSHIP
PLEASE READ THIS MESSAGE FROM THE BP BEFORE FILLING OUT THE APPLICATION
If you are unsure of which Community Board you belong to,
click here
or contact Marie Carmody-LaFrancesca at
mlafrancesca@statenislandusa.com
or 718-816-2141.
Community Board Membership Application
Please note: You must be a New York City resident to qualify for a particular board and you must live, work, or have a professional or other significant interest in that board's district. Additionally, the Freedom of Information Law (FOIL) may allow for public review of this application upon request; therefore some information given on this document may be subject to disclosure under FOIL. Please type clearly and so not leave any area blank. If a question does not apply, please indicate by writing "N/A" in the space provided.
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Indicates required field
DATE:
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1. I am applying for membership on Community Board #
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To which Board do you seek appointment?
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a. The Board, which covers the area where you live.
b. The Board, which covers the area where you work.
2. NAME:
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DATE OF BIRTH:
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3. HOME ADDRESS (Street/Borough/State/Zip)
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4. Length of Residence on Staten Island
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Length of Residence in Community Board
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5. TELEPHONE (Home)
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TELEPHONE (Business)
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EMAIL ADDRESS
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6. If you seek appointment to the Board in which you have a business or other interest, describe the nature of that interest.
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7. Civic, Fraternal and Community Organization(s) in which you are active.
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8. Special skills or interests. Please specify:
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9. Do you have any professional certificates or licenses?
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10. Occupation:
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Present Employer:
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Present Employer Address:
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Position or Title:
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11. Are you an employee of the City of New York?
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Yes
No
Which division or agency do you serve?
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12. Work or school experience for the last 10 years.
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13. Are you employed by or associated with any entity whose contrast or program comes before a Community Board for a funding request or review?
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Yes
No
14. If the answer to the above question (#13) is YES, name the agency, organization or entity.
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15. Is any member of your family employed by or associated with an entity whose contract or program comes before a Community Board for a funding request or review?
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Yes
No
16. If the answer to the above question (#15) is YES, name the agency, organization or entity.
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17. EDUCATION
High School Attended
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If not applicable, write N/A.
Year Graduated H.S.
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If not applicable, write N/A.
Diploma
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If not applicable, write N/A.
College Attended
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If not applicable, write N/A.
Year Graduated College
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If not applicable, write N/A.
Degree
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If not applicable, write N/A.
Post Graduate Degree
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If not applicable, write N/A.
18. If appointed, in which of the following substantive areas of activity would you prefer to be involved?
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Housing
Transportation
Sanitation
Arts & Culture
Consumer Affairs
Planning & Zoning
Health & Hospitals
Parks & Recreation
Senior Citizen Affairs
Education
Finance & Budget
Public Safety
Environment & Ecology
Other area. Please specify:
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19. Why do you seek appointment to the Community Board?
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DEMOGRAPHIC PROFILE
Community Board #
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CB 1
CB 2
CB 3
Age
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16-17 years (16 by April 1st)
18-19 years old
20-29 years old
30-39 years old
40-49 years old
50-59 years old
60+ years old
Prefer Not to Answer
Gender
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Female
Male
Transgender
Gender non-conforming
Prefer Not to Answer
Do you have any disabilities?
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Yes
No
Prefer Not to Answer
If yes, what type of disability?
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Which of the following best describes how you identify? Select all that apply:
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African American/Black
Asian American
Caribbean / West Indian
East Asian / South East Asian / Pacific Islander
Latina/o/x/ Hispanic
Middle Eastern / North African
Native American / American Indian
South Asian
Sub-Saharan African
White / European
Prefer Not to Answer
Any other background info you would like for us to know? Select all that apply.
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Caregiver
Immigrant
LGBTQ
Non-native speaker of English
Parent / guardian of a Pre K-12 child
Parent / guardian of a Preschooler
Parent / guardian of a person with a disability
Person with a disability
Veteran / military service
Prefer Not to Answer
Educational Attainment
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Some High School
High School Degree or Equivalent
Some college credit, no degree
Trade/technical/vocational training
Associate Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Law Degree
Medical Degree
Prefer Not to Answer
Language(s) Spoken:
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REFERENCES:
Reference #1: (Name/Address/Telephone)
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Reference #2: (Name/Address/Telephone)
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Reference #3: (Name/Address/Telephone)
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Please click the "Submit Application" button below or
download and print the hard copy
and mail to:
Office of the Staten Island Borough President
10 Richmond Terrace, Room 100, Staten Island, NY 10301
Attn: Director of Community Boards
It is the responsibility of Community Board applicants to notify this office of any changes in residence, business or work location that would affect their membership on the community board.
Please note: You must be a resident of New York City to be eligible for community board membership.
For additional information, please contact Marie Carmody-LaFrancesca at the Borough President's Office at
mlafrancesca@statenislandusa.com
or 718-816-2141.
SUBMIT APPLICATION
