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2. 
3. Rohnert Park Department of Public Safety

   Community Round Table Application

5. First Name*
6. Last Name*
7. Phone Number*
9. Email Address*
10. Date of Birth
    Date of Birth
11. Driver License or ID #
13. What Section of Rohnert Park do you live in?
14. Occupation
15. Employer
17. Address*
19. City*
20. State*
21. Zip Code*
23. Interest*

    Please describe why you are interested in joining the CRT.

25. Experience*

    What skills, experience, and/or expertise do you bring to the CRT? How do you see these skills and experiences contribution to the CRT?

27. Issues and Challenges*

    What do you see as the top three public safety issues or challenges facing Rohnert Park?

29. Community/ Volunteer Activities*

    Please list community/ volunteer activities with which you have been involved in the last five years.

31. Information Dissemination*

    Please describe your ability to distribute information to the community and encourage participation. You may include your experience with other types of engagement or community events/organizations.

33. Sector(s) or stakeholder audience(s) you would present on the CRT?*

    1. Youth representative (Rohnert Park-Cotati Unified School District high schools)
    2. Sonoma State University (SSU) representative
    3. Black community
    4. Indigenous community
    5. Latinx community
    6. Asian and Pacific Islander
    7. Business representative
    8. Faith community representative
    9. LBGTQ+
    10. Other individuals not listed above
34. Gender*

    1. Female
    2. Male
    3. Non-binary
    4. Prefer not to state
    5. Prefer to self-identify
35. Ethnicity*

    1. Asian
    2. Black or African American
    3. Hispanic or Latinx
    4. Native American or Alaska Native
    5. Native Hawaiian or other pacific islander
    6. White or Caucasian
    7. Prefer not to state
    8. Prefer to self-identify
37. Signature*

    Type first and last name

38. Date*
    Date
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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