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// <br />FOR OFFrCE USE ONLY <br />19 62 -~aw n C . P;cke+~+ <br />VOLUNTEER APPLICATION <br />ORANGE COUNTY ADVISORY BOARDS AND COMMISSIONS <br />If you are an Orange County resident, at least 18 years old, and willing to vo <br />expertise to your community, please complete this application and return to D <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 Emaii: npaciga~co.orange.nc. <br />~FEB i 9 zo02 <br />~! <br />., <br />r :;; <br />J1 i <br />NAME: 1.y-Q,ccr/(, ~ , ~,(~~~,~; <br />HOME ADDRESS: /D <br />CITY: ~~~~ ~,(,LU ~ . ~! _ Zip Code:_ <br />-~ <br />PHONE: (Day) (9~9) 9'.t9-~gG S~ (Evening/late) gr9~4~q_~gG s- (Fax) <br />EMAIL: 9.%o~d~t-c~Jn ~ f'1.bfima~t;E.. Ccrr-~ <br />T- <br />PLACE OF EMPLOYMENT: !.t ~ awn ~, /a,.. i~ JOB TITLE: <br />~2°7S/ ~ <br />IN ORDER TO ASSURE COUNTYWIDE REPRESENTATION.PLEASE INDICATE YOUR TOWNSHIP <br />OF RESIDENCE: <br />O gingham .0 Cheeks O Hillsborough O Eno ~Chape! Hill O Little River- O~CedarGrove~ <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 MEMBERSHIP BY AGE, GENDER AND RACE, <br />BY ANSWERING THE FOLLOWING DUESTIONS: O Male ~ Female <br />ETHNIC BACKGROUND: O African American Q~ Caucasian O Hispanic O Native American <br />O Other DATE OF BIRTH: //_~-~r5" <br />PLEASE LIST (IN ORDER OF PREFERENCE) THE BOARDS/COMMISSIONS ON WHICH YOU <br />WOULD BE WILLING TO SERVE. <br />1• 1~u.f~SYIG (a C~ l'. 2. ~ i~• .f~'r~ GFf'(~ 3. ~rv- nM,.54s-i r~~B-~ (.17Ul~dJ~- <br />~ ~ f M,LrI <br />WORK EXPERIENCE: <br />CD / P ' ~.cr-~' <br />VOLUNTEER <br />