Agenda - 05-06-2003 - 9-d-4 - Laserfiche WebLink

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FOR OFFICE USE ONLY VOLUNTEER APPLICATION ORANGE COUNTY ADVISORY BOARDS AND COMMISSIONS If you are an Orange County resident, at least 18 years old, and willing to expertise to your community, please complete this application and return ' Orange County Commissioners' Office P.O. Box 8181 Hillsborough, NC 27278 Phone (919) 245-2125; 245-2129; 245-2130; 732-818 Fax: (919) 644-0246 Email: ncglover@co.orange. NAME: HOME ADDRESS: CITY: 1 ~~~ r time and ~~ ....._ ~.: i Zip Code: ~~ ~~~ PHONE: (Day) `'~1 `c~ (Evening/late)~ ~J2- ~rj~p~] (Fax) CX . Z ~{ EMAIL: PLACE OF EMPLOYMENT~~ ~ ~ ,.J~~'.SJOB TITLE: ~~ C~~~C~ IN ORDER TO ASSURE COUNTYWIDE REPRESENTATION PLEASE INDICATE YOUR TOWNSHIP OF RESIDENCE: ~' Bingham OCheeks TdHillsborough ^ Eno OChapei Hiil ~Littie River t7Cedar Grove IN ADDITION, PLEASE INDICATE IF YOU LNE IN ONE OF THE FOLLOWING AREAS: Qloint Planning Area ClExtraterritorial Area t71'ransition Area WE ASK YOUR HELP IN ASSURING DNERSITY OF MEMBERSHIP BY AGE, GENDER AND RACE, BY ANSWERING THE FOLLOWING QUESTIONS• ^Male ~I`e'male ETHNIC BACKGROUND: ^African American ~aucasian l7Hispanic Native American Other DATE OF BIRTH: --3 0 r- S~ PLEASE LIST (IN ORDER OF PREFERENCE) THE BOARDSICOMMISSIONS ON WHICH YOU WOULD BE WILLING TO$ERVE. ,EfL~t~3D C~iG3~C 1. 2. 3. WORK EXPERIENCE: VOLUNTEER EXPERIENCE: ()c~~~ ~~ ~_ ~,~y ~~~