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2. Boards and Committee List*
   -- Select One --Board of EqualizationBoard of HealthBoundary Review BoardBuilding & Planning Advisory CouncilCivil Service Commission for Sheriff's DepartmentDisability Advisory BoardDiking DistrictsFair and Rodeo BoardGreat Rivers Behavioral Health Advisory BoardHistoric Preservation CommitteeHomeless Housing Task ForceLodging Tax Advisory CommitteeMosquito Control DistrictNoxious Weed Control BoardPark & Recreation Advisory BoardPlanning CommissionPublic Facilities District BoardRural Partial-County Library District Board of TrusteesSilver Lake Watershed Advisory CouncilSolid Waste Advisory CommitteeSouthwest Washington Workforce Development CouncilStormwater Advisory CommitteeVeterans Advisory BoardYale Valley Library District Trustee

   Please select the Board or Committee.

3. Application*

   1. New to the Committee
   2. Re-appointment to the Committee
5. Board of Health Representing:*
   -- Select One --Public Health, Healthcare Facilities, or ProvidersConsumers of Public HealthOther Community Stakeholders
6. Building & Planning Representing:*
   -- Select One --Lower Columbia Contractors Association (LCCA)Economic Development Council (EDC)General ContractorLower Columbia RealtorsEnvironmental CommunityDevelopment CommunityCitizen-at-Large District 1Citizen-at-Large District 2Citizen-at-Large District 3
7. Disability Advisory Board Representing:*
   -- Select One --FirefightersSmall CitiesLaw Enforcement OfficersCitizen At Large
8. Historic Preservation Committee Representing:*
   -- Select One --ProfessionalDistrict 1District 2District 3
10. Homeless Housing Task Force Representing:*
    -- Select One --General MemberCounty GovernmentCity of KelsoCity of Longview
11. Lodging Tax Advisory Committee Representing:*
    -- Select One --ReceiversCollectors
12. Mosquito Control District Representing:*
    -- Select One --District 1District 2District 3City of KelsoCity of LongviewCity of KalamaCity of Castle RockCity of Woodland
13. Noxious Weed Control Board Representing:*
    -- Select One --District 1District 2District 3
15. Park & Recreation Advisory Board Representing:*
    -- Select One --District 1District 2District 3Member-at-large
16. Planning Commission Representing:*
    -- Select One --District 1District 2District 3
17. Solid Waste Advisory Committee Representing:*
    -- Select One --CitizensAgriculturalCity of KelsoCity of LongviewSmall Cities - Kalama, Woodland & Castle RockWaste Management IndustryLarge Industry
18. Diking District Number*
20. Fair or Rodeo Board Representing:
    -- Select One --Fair BoardRodeo Board
22. Public Health, health care facilities, and providers*

    Are you practicing or employed in the county or health district as a

    • Medical ethicist
    • Epidemiologist
    • Experienced in environmental public health
    • Community health workers
    • Holder of master's degree or high in public health or another field with an emphasis or concentration in health care, public health, or health policy
    • Employees of a hospital located in the county

    Or, do you hold an active or retired license in good standing under Title 18 RCW; specifically, for one of the following:

    • Physician or osteopathic physician
    • Advanced registered nurse practitioner
    • Physician Assistant
    • Registered Nurse
    • Dentist
    • Naturopath
    • Pharmacist

    If yes, please explain.

24. Consumers of Public Health*

    Are you a county resident who has self-identified as having faced significant health inequities or as having lived experiences with public health-related programs? If yes, please explain.

25. Other Community Stakeholders*

    Do you represent one of the following types of organizations located in the county:

    1. Community-based organizations or nonprofits that work with the populations experiencing health inequities in the county
    2. Active, reserve, or retired armed services member
    3. The business community
    4. The environmental public health regulated community

    If yes, please explain.

27. Personal Information
29. First Name*
30. Last Name*
32. Address1*
33. City*
34. State*
36. Zip*
37. Home Phone Number*
38. Length of Residency the County*
40. Email Address*
41. Occupation*
43. Are you a registered voter?*

    1. Yes
    2. No

    All members must be registered voters.

44. Are you a resident of Cowlitz County?*

    1. Yes
    2. No

    All members must be residents of Cowlitz County and if applicable, reside in the area they represent.

46. Organization Membership Information
48. Are you currently serving on other Boards, Commissions, or Committees?*

    1. Yes
    2. No
49. If yes, which
51. Could you please list any other organization memberships you currently hold and any positions you occupy within those organizations?
52. Why are you interested in this position/opportunity?*
54. Can you describe your professional background and personal experiences? How do these contribute to a diverse range of expertise and perspectives?*
55. Can you tell us about your background and how your experiences reflect the geographic diversity of our community?*
57. Do you have any personal or professional relationships, affiliations, or interests that could potentially conflict with your duties and responsibilities in this role? If so, please describe them.*
58. Can you share how your professional expertise and personal experiences bring diverse perspectives to our team? How do you believe your background will contribute to our organization's goals and culture?*
60. If you are applying for the Consumers of Public Health position: Do you have any fiduciary obligations to a health facility or other health agency, or hold any material financial interests in the rendering of health services? If so, please provide details.*
61. If you are applying for the Consumers of Public Health position: Do you identify with a historically underrepresented community? If yes, explain below.*
63. Describe your demonstrated commitment to public health:*
65. Reference #1 - First Name*
66. Last Name*
67. Phone Number*
68. Email*
70. Reference #2 - First Name*
71. Last Name*
72. Phone Number*
73. Email*
75. Reference #3 - First Name*
76. Last Name*
77. Phone Number*
78. Email*
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field