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2. First Name*
3. Last Name*
5. Home Address*
7. City*
8. State*
9. Zip*
11. Cell or Main Phone*
12. Other Phone
14. Email Address*
16. Preferred Method of Contact*

    1. Email
    2. Cell or Main Phone
    3. Other Phone
18. Occupation
20. Employer Name
22. Are you age 18 or older?*

    1. Yes
    2. No
24. Do you identify as Hispanic origin?*
    -- Select One --Not of Hispanic, Latino, or Spanish originMexican, Mexican American, or ChicanoPuerto RicanCubanAnother Hispanic, Latino, or Spanish Origin (for example, Salvadoran, Dominican, Guatemalan, etc)
26. What is your race?*
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOther
28. If you selected "Other" for race, please specify:
30. Are you currently serving on a City or County commission or committee? *

    1. Yes
    2. No
32. If so, please specify which commission or committee and when your term expires:
34. The Racial Justice and Equity (RJE) Commission serves as the steering body for the overall RJE initiative. This commission guides the work, oversees the committees, collects and analyzes information, explores strategies, develops resources, and communicates progress via periodic reports to the Peoria City Council and Peoria County Board.
36. Under the commission, there are multiple committees on which to serve. These committees are committed to working on action issues within our community with a racial justice and equity lens.
38. Please rank your FIRST choice for what you would like to serve on.*
    -- Select One --Commission on Racial Justice and Equity (steering committee)Child and Youth Development committeeEconomic Development and Jobs committeeEnvironment and Climate committeeHealth and Human Services committeeHousing committeeInformation and Technology committeeJustice System committeeTransportation and Mobility committee
40. Please selection your SECOND choice for what you would like to serve on.
    -- Select One --Commission on Racial Justice and Equity (steering committee)Child and youth development committeeEconomic development and jobs committeeEnvironment and climate committeeHealth and human services committeeHousing committeeInformation and technology committeeJustice system committeeTransportation and mobility committee
42. Please select your THIRD choice for what you would like to serve on.
    -- Select One --Commission on Racial Justice and Equity (steering committee)Economic Development and Jobs committeeEnvironment and Climate committeeHealth and Human Services committeeHousing committeeInformation and Technology committeeJustice System committeeTransportation and Mobility committee
44. Can you commit to monthly meetings, at least two hours per month?*

    1. Yes
    2. No
46. What is your availability to meet?*

    1. Daytime
    2. Evenings
    3. Either daytime or evenings
48. As a member of the Commission, you will be expected to participate in specific racial justice and equity training, small group facilitator training, and open meetings act training. Are you willing to participate in this training?*

    1. Yes
    2. No
50. Please complete the following as it relates to the relevancy of the commission/committee you are applying for:
52. Educational Background
54. Professional and Employment Background
56. Community Volunteer Experience
58. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I certify that the above information is true and correct.

    1. I agree.
60. Electronic Signature
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62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

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