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~~o <br />~~• <br />~~ ~,~. <br />'-~r~,.. ,oy~~ Date Received <br />Application for: Authorities, Boards, Commissions, and Committees <br />Note: All information on this document will be released to the public on request. <br />PLEASE P R I N T clearly: <br />Name: Ethnic Background: <br />Sex: (M) (F)_ <br />Home Phone Number: Age (over 18): Yes No <br />Home Fax Number: <br />Email Address: (Please provide this contact inforrrurt~) <br />Home Address: <br />(street) (city) (state) (zip) <br />Name of Authority/Board/Commission/Committee: <br />Specific category applying for: (e.g. Nurse, Attorney, At-Large, etc.) <br />Qualification for specific category: <br />Occupation: <br />Place of Business: <br />Business Address: <br />(street) <br />Business Phone Number: <br />Do you live within Durham County? Yes <br />Do you live within the corporate city limits? Yes <br />Education: <br />(city) <br />Business Fax Number: <br />No Township: _ <br />No <br />(state) (zip) <br />11 <br />