Agenda - 01-20-2000 - 11 - Laserfiche WebLink

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FOR OFFICE USE ONLY y ! a .? �9cvenG�o� 17iCe VOLUNTEER APPLICATION ORANGE COUNTY BOARDS AND COMMISSIONS are an Orange County resident, at least 18 years old, and willing to volunteer your and expertise to your cammunity, please complete this application and ttr+etum_to: Orange County Commissioners' Office Le _____ P.O. Box 8181 Hillsborough, NC 27278 7 Phone ( 919) 7328181; 6'88-7331; 968- 4501; 227,203 �Ext 21259 2129 or 2130 • Fax: (919) 644 -0246 NAME. ►�'� �� ri HOME AD j CITY• - G zip code: ©? 7.70 3 TELEPHONE: (H) 'S / l (W) �Y (Fax)- EMAIL: i t - Q/JS u , - A/G , 0 S PLACE OF EMPLOYMENT: IN ORDER TO ASSURE COU TOWNSHIP OF RESIDENCE: JOB TITLE: �'t REPRESENTATION PLEASE INDICATE YOUR Cheeks Eno Chapel "In, Little lVr Cedar Grave IN ADDITION, PLEASE INDICATE IF YOU LIVE IN ONE OF THE FOLLOWING AREAS: Joint Planning Area Extraterritorial Area Transition Area WE ASK .YOUR HELP IN ASSURING DIVERSITY OF MEMB HIP BY AGE, GENDER AND RACE, BYANSWERING THE FOLLOWING QUESTIONS: Male ETHNIC BACKGROUND:- Female ✓ African American Caucasian Native American DATE OF BIRTH: PLEASE LIST (IN ORDER OF PREFERENCE) THE YOU WOULD BE WILLING Zj TO SERVE. 2 3.. Hispanic„_ Other PARDStCQMMISSiONS. ON WHICH •�� dta cz,,