The Town Council of Purcellville accepts applications on an ongoing basis from citizens who are interested in serving
on one of our appointed boards, committees, or commissions. The Town relies heavily on citizens to staff our advisory
organizations. Please take time to complete the following information.

The information provided with this application is public information and
I acknowledge that interviews are generally conducted during a public meeting.*

I understand

Salutation*

Mr. Mrs.

Ms.

Full Name:*

Phone #:

Street Address:*

Mailing Address (if different than above):

City, State, Zip*

Email Address:*

Does the applicant have a financial interest in, or is the applicant related to anyone with a financial interest in, any matter that is
either pending before the Committees, Commissions & Boards or is likely to come before the Committees, Commissions & Boards? *

Yes

No

If Yes, please explain:

Please check any of the Committees, Commissions or Boards in which you would like to be considered for appointment:*

Board of Architectural Review Board of Zoning Appeals Community Policing Advisory Committee Economic Development Advisory Committee Parks and Recreation Advisory Board

Planning Commission Purcellville Arts Council Town Council (when vacancy occurs) Train Station Advisory Board Tree and Environment Sustainability Committee

Please describe your interest in being part of the Town’s governmental process and how you feel you can contribute.
You may also attach a letter of interest and/or resume (PDF files only). *

Attach Resume

Attach Letter of Interest

Members of the Planning Commission, Board of Architectural Review, Economic Development Advisory Committee
and Community Policing Advisory Committee are issued town email addresses. All town business will be communicated
through town email and not personal email. I acknowledge that if I am appointed to one of the committees mentioned,
I will be issued and use a town email address to conduct the business of the town.

Yes

No

For questions, please email Diana Hays at dhays@purcellvilleva.gov or call 540-751-2334.