Form Center

* indicates a required field

2. Contact Information
4. Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Primary Phone Number*
13. Email Address*
15. Preferred Method of Contact*
    -- Select One --Phone callEmailText message
19. About Boards & Commissions
21. Which boards and commissions are you interested in joining?

    Check all that apply.  

    1. Board of Public Works
    2. Brownfield Redevelopment Authority/Economic Development Corporation
    3. Canvassing Board
    4. Cass District Library Board
    5. Community Corrections Advisory Board
    6. Department of Human Services/Medical Care Facility
    7. Historical Commission
    8. Kinexus (Workforce Development)

    1. Land Bank Authority
    2. Opioid Settlement Advisory Committee
    3. Parks and Recreation Commission
    4. Planning Commission
    5. Road Commission
    6. Van Buren/Cass District Board of Health
    7. Veterans Services Board
    8. Woodlands Behavioral Healthcare Board
23. Are you a member of a congressionally chartered veterans organization (i.e. VFW or American Legion)?

    1. Yes
    2. No
25. Were you honorably discharged?

    1. Yes
    2. No
27. If possible, please upload a copy of your DD-214.
29. VOLUNTARY BIOGRAPHICAL INFORMATION:

    According to Mental Health Code Act 258  of 1974 MCL Section 330.1757, which regulates the Woodlands board, "At least four (4) members must be consumers, or their family members, of mental health services and of those at least two (2) must be primary consumers." “Primary consumer” means an individual who has received or is receiving services from the Department of Health and Human Services (the “Department”) or the Authority, or services from the private sector equivalent to those offered by the Department or a community mental health services program.

    Do you meet this additional requirement?

    1. Yes
    2. No
31. Referral Source

    1. County Official
    2. Friend
    3. Social Media
    4. County Website

    1. Newspaper
    2. Relative
    3. Government Official
    4. Other
33. If "Other", please specify:
35. Employment Background*

    Please briefly list any employment experience that would benefit you on the board or commission for which you are applying. 

37. Civic/Volunteer Involvement*

    Please list all volunteer/nonprofit experience that may benefit you in this position.

39. What skills or qualities do you possess that would make you a good fit for this position?*
41. What do you hope to accomplish in this role?*
43. References

    Please list two non-familial references and their contact information.

45. Name*
46. Phone or Email Address*
48. Name*
49. Phone or Email Address*
53. Demographic Information
55. In order to track the effectiveness of our appointments process and ensure we consider the needs of all our county residents, please consider the following optional questions. Cass County Government does not discriminate on the basis of race, color, age, gender identity, or any other basis of discrimination prohibited by law.
57. Are you a resident of Cass County?*

    1. Yes
    2. No
58. Are you a citizen of the United States?*

    1. Yes
    2. No
60. Are you related to any Cass County employee?*

    1. Yes
    2. No
62. If yes, who are you related to?*
64. Have you ever been convicted of a felony?*

    1. Yes
    2. No
66. If yes, please explain:
68. Age

    1. Under 18
    2. 19-25
    3. 26-35
    4. 36-45

    1. 46-55
    2. 56-65
    3. 66-75
    4. 76+
69. Highest Level of Education

    1. Grade School
    2. High School Diploma
    3. Associate's Degree
    4. Vocational Certificate

    1. Bachelor's Degree
    2. Master's Degree
    3. PhD or Doctoral Degree
71. Electronic Signature Agreement
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.