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Statement of Qualifications <br />for <br />Certified Local Governments Commissioners <br />Local Government <br />Name of Commissioner <br />Date of Appointment: <br />Date Term Expires: <br />Certified Local Government procedures require local commissions to meet <br />specific professional requirements. The commission shall include a minimum <br />membership of five individuals with all members having demonstrated interest, <br />competence, or knowledge in historic preservation. Commission membership <br />may also include lay members who have demonstrated special interests, competence, <br />experience, or knowledge in historic preservation. <br />At least two Commission members are encouraged to be appointed from among <br />professionals in the disciplines of history, architecture, architectural history, planning, <br />pre -historic and historic archeology, folklore, cultural anthropology, curation, conservation, <br />and landscape architecture or related disciplines, such as urban planning, American <br />studies, American civilization, or cultural geography, to the extent that such <br />professionals are available in the community. <br />Are you a professional in one of the disciplines associated with historic preservation? <br />Yes No <br />Summarize you qualifying education, professional experience, and any appropriate licenses <br />or certificates. Attach a resume. <br />Rev 11/22/10 <br />C-24 <br />