AF2 - Mid-Term Elected Position Appointment Verification of Qualifications

Instructions: This form is to be filled out by conservation district personnel only. To ensure the appointee is qualified to serve, this form should be filled out before the appointee is appointed to fill a vacant, mid-term elected position. This form is to be used ONLY when a conservation district is seeking to fill a mid-term vacancy to an elected supervisor position. The conservation district must determine a prospective appointee's eligibility to fill the public office of an elected conservation district supervisor. This information will be reviewed by the Washington State Conservation Commission.

Please Select Conservation District:*

YOU HAVE NOT CHOSEN YOUR CONSERVATION DISTRICT. PLEASE CHOOSE YOUR CONSERVATION DISTRICT BEFORE PROCEEDING FURTHER!

Name of conservation district staff filling out this form:*

First Name

Last Name

Email address of conservation district staff filling out this form:*

Applicant Name (if no middle name, please enter "none"):*

First Name

Middle Name

Last Name

Applicant Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Applicant Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Applicant Day Phone*

Applicant Email*

Applicant Cell Phone

Date applicant will be appointed to fill the remainder of the elected term*

This applicant is replacing which elected board member?

If the position to be filled is currently vacant, please write "vacant" above.

Verification of appointee eligibility*

The appointee is a qualified district elector (registered voter living inside the conservation district boundaries).

The conservation district must verify the eligiblity of the appointee to hold the public office of conservation district supervisor. WAC 135-110-930.

Verification of statutory board composition*

If this appointed is appointed to the open elected position, at least two of the three elected conservation district supervisors will be landowners or farm operators.

The conservation district must verify that the board composition resulting from appointment of this applicant will meet the statutory requirement that at least two of the three elected supervisors must be landowners or operators of a farm. WAC 135-110-355(2)e.

If both boxes immediately above are checked, the applicant is eligible to serve the remainder of the open elected positions' term.

By submitting this form I attest I am an employee of the conservation district and that the information above is accurate, true and correct, to the best of my knowledge.*

First Name

Last Name

Washington State

CONSERVATION COMMISSION