All applicants must complete this information page and the "affidavit of identity form".   Please print or type.  This form must be completed and returned to the Police and Public Safety Department, 422 N. Washington Square, Gannon Vocational-Technical Center, Room 2800 by 12 Noon on Monday, January 6, 2003.

Name:_____________________________________________________________________________

Address:___________________________________________________________________________

City: ____________________________________________  State: _______________  ZIP: __________

1. Briefly state why you want to be appointed to the Lansing Community College Board of Trustees.

2. List current and past memberships, responsibilities and activities in civic and community organizations.

3. Briefly indicate your work history.

Signature of Applicant:________________________________________________   Date: ___________________