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FOR OFFICE USE ONLY <br />r <br />10F s Ga C, kress C C� 19 16 'I i <br />VOLUNTEER APPLICATION <br />ORANGE COUNTY ADVISORY BOARDS AND COMMISSIONS I 0 <br />If you are an Orange County resident, at least 18 years old, and willing to vol <br />expertise to your community, please complete this application and return to: <br />Orange County Commissioners' Office <br />P.O. Box 8181 <br />Hillsborough, NC 27278 <br />Phone (919) 245.2125; 245 -2129; 245 -2130; 732.8181 <br />Fax: (919) 644.0246 - Email: npac19a0_co.orange.nc.us <br />NAME: <br />HOME ADDRESS: 0 2 <br />CITY:- /Z. ! Zip Code•...,2 0_61 L.7 <br />PHONE: (Day) 96e 7-. T 2 Ai (Eveningllate) Q(_i• . 3'n R/ (Fax) _ !y ZA <br />/ <br />EMAIL: C 1K0 z. r. r 2 fx),q z& Ze Ae c- 1A1�— 7— <br />PLACE OF EMPLOYMENT: r r. JOB TITLE: <br />IN ORDER TO ASSURE COUNTYWIDE REPRESENTATION PLEASE INDICATE YOUR TOWNSHIP <br />OF RESIDENCE: <br />O Bingham O Cheeks O Hillsborough O Eno 02 Chapel Hill O Little River O Cedar Grove <br />IN ADDITION, PLEASE INDICATE IF YOU LIVE IN ONE OF THE FOLLOWING AREAS: <br />O Joint Planning Area O Extraterritorial Area O Transition Area <br />WE ASK YOUR HELP IN ASSURING DIVERSITY OF "MBERSHIP BY AGE, GENDER AND RACE, <br />BY ANSWER114G THE FOLLOWING QUESTIONS: . (0 Male O Female <br />ETHNIC BACKGROUND: O African American PCaucaslan O Hispanic O Native American <br />O Other DATE OF BIRTH: / Q - ?. ? -, f 2 <br />PLEASE LIST (IN ORDER OF PREFERENCE) THE BOARDSMOMMISSIONS ON WHICH YOU <br />WOULD BE WILLING TO SERVE. <br />e� • d <br />WORK EXPERIENCE: <br />VOLUNTEER EXPERIENCE; <br />SC <br />tie <br />db✓ cG- Airs' <br />