Agenda - 01-31-2012 - 4 - Laserfiche WebLink

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NEW HANOVER COUNTY BOARD OF COMMISSIONERS 230 Government Center Drive, Suite 175 Wilmington, NC 28403 COMMITTEE APPLICATION Telephone (910) 798-7149 FAX (910) 798-7145 Board/Committee: Name: E-Mail: 23 ~~ ~~' ~=1 Home Address: reet y ~p o e Mailing Address if different: Home Phone: (City) (Zip Code) Fax: Cell: Business: Years living in New Hanover County: Male: Female: Race: Age: (Information for the purpose ofassuring across-section of the community) Do you have a family member employed by New Hanover County? ff yes, name Employer. A person currently employed by the agency or department for which this application is made, must resign his/her position with New Hanover County upon appointment in accordance with Artide Vl, Sec. 4 of the New Hanover County Personnel Policy. Furthemrore, applicant should have no immediate family member employed by such agency or department. Occupation: Professional Activities: Volunteer Activities; Why do you wish to serve on this board/committee? Conflict of Interest: ff a board member believes he/she has a conflict or potential conflict of interest on a particularissue, that member should state this belief to the other members of his/her respective board during a public meeting. The member should state the nature of the conflict detailing that he/she has a separate, private, or monetary interest either direct or indirect, in the issue under consideration. The member should then excuse himself/herself from voting on the matter. What areas of concern would you like to see addressed by this committee? Qualifications for serving: Other municipal or county boards/committees on which you are serving: List three local personal references and phone numbers: 1. 2. 3. Date: Applications are kept on file for 18 months Please use reverse side for additional comments Signature I understand that any board or committee appointee maybe removed without cause by a majority of County Commissioners.