Orange County NC Website
rs; , <br /> . . <br /> AGENDA ATTACHMENT 14-D <br /> rt <br /> CAPITAL HEALTH SYSTEMS AGENCY , INC,. <br /> 3600 North Duke Street <br /> Durham, N. C. 27704 <br /> Capital he '' <br /> AgoncY. In <br /> PROSPECTIVE MEMBERSHIP QUESTIONNAIRE <br /> (Physical handicap not a deterrent to membership) <br /> A. BIOGRAPHICAL INFORMATION <br /> (Where blanks appear, please provide the appropriate response, ) <br /> 1. Name Cc11,1,9,-(-KL04.4 ) F.-Bur/re-4p (Please Print) <br /> Business Address g457t30y1 ,2 <br /> Employer Name/Occupation/Profession/Title /;7-5 <br /> .SC.L2 &CI "•• e/o/ 2)/rec7ipt- r- rori Co <br /> Horne Address c7?4_, 0 A._ Joo /14 J7 ane „/CC 7,3 <br /> - Telephone: Home 3ez...7-3-..24. 4. Business <br /> 2. Sex: Male Female <br /> 3. Age Group: 18-34 35-44 45-64 <br /> 65 & Over <br /> 4. Family Income: Less Than $10,000 $15,000-$24 999 <br /> $10,000 - $14,999 $25,000 or more <br /> 5. Race: White Nonwhite '- <br /> 6. Education: 12 years or less 13-16 years <br /> 16 years or more <br /> 7. Are you being nominated to represent low income and/or disadvantage( <br /> - rxt. a-C„ ' <br /> B. List Major Organizational Memberships: <br /> 12%4 ,1,„„,;.,,..15.4,4,- c/a 0/7; S 4 r <br /> d2r‘r.-4.1 e•re.--r,/ gc.4 /5 <br /> 4.:5"...s.7.41 , s <br /> I . <br /> 61, <br />