Priority Setting Committee (PSC) Application Form

Priority Setting Committee (PSC) Application Form
Applicant Information
Applicant Name*

First NameLast Name
Applicant Email Address*
example@example.com
Do you live in Marin County?*

YesNo
We are unable to proceed with your application. PSC members must live in Marin County.
Primary Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Under federal fair housing laws, "protected classes" include race, religion, color, national origin, sex, disability, and familial status. For this PSC recruitment, we are seeking individuals who are members of a racial or ethnic minority, people with disabilities, and/or people who represent these interests.
List any federal protected classes you are a member of or represent. Representing a protected class is not a requirement; enter Not Applicable if this does not apply to you:*
Are you over 18 years of age?*

YesNo
We are unable to proceed with your application. PSC members must be over 18 years of age.
Are you employed?*

YesNo
Current Occupation*
Employer's Name*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you be representing an organization in your PSC membership?*

YesNo
Name the organization you would represent*
County region to represent (includes neighboring unincorporated areas)

Larkspur, Corte Madera, Kentfield and GreenbraeNovatoSan RafaelWest Marin
County region to represent (includes neighboring unincorporated areas)

Fairfax, Ross, San Anselmo, and adjacent unincorporated communitiesBelvedere, Mill Valley, Sausalito, Tiburon, and adjacent unincorporated communities, including Marin City and Tam ValleyCountywide, at-large member
County region to represent (includes neighboring unincorporated areas)

Larkspur, Corte Madera, Kentfield, and GreenbraeNovatoSan Rafael, including the Canal neighborhoodWest Marin, including the coastal corridor from Muir Beach to Dillon Beach, Point Reyes, and inland communities such as Nicasio and the San Geronimo ValleyCountywide, at-large member
Narrative Information
Please describe your reasons for applying to be a member of the Priority Setting Committee.*

0/1000
While it is illegal to discriminate in housing-related transactions based on race, color, religion, national origin, sex, disability, and familial status under fair housing laws, reports show that such discrimination continues to occur.
What services, if any, do you see are needed in Marin County for members of these protected classes to access information, opportunity, and options to live where they choose without discrimination? *

0/1000
Please describe any other relevant experience you bring to the PSC.

0/1000
Has any organization of which you are an officer or employee received federal funds from the County, or plans to request such funds in the future? (Federal funds include the Community Development Block Grant (CDBG) and HOME programs.)*

YesNo
An applicant who is an employee or an officer of an organization that receives CDBG or HOME funding may not be eligible to serve as a Committee Member due to a potential conflict of interest. Refer to the Code of Federal Regulations for more information.
List Organizations*
Documents
Please feel free to attach any additional documents or information pertaining to your candidacy for the Priority Setting Committee.
File Upload

Allowable file types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
NOTE: This application will remain valid for a period of one year. The County may require Committee Members to file a financial disclosure form (listing sources of income, interests in real property, investments, and business positions), which will be a public document.
By checking this box*

I certify that all information included in and attached to this application form is true and correct.
Should be Empty:

Priority Setting Committee (PSC) Application Form

Applicant Information

Narrative Information

Documents