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_ <br /> • <br /> AGENDA ATTACHMENT 14 -0 <br /> CAPITAL HEALTH SYSTEMS AGENCY <br /> 3600 North Duke Street <br /> Durham, N. C. 27704 <br /> NOV 3 Nr <br /> PROSPECTIVE MEMBERSHIP QUESTIONNAIRE <br /> '4y;tarrir <br /> inc. <br /> A. BIOGRAPHICAL INFORMATION <br /> (Where blanks appear, please check the appropriate response.) <br /> I. None Eric B. Munson (Please Print) <br /> Business Address General Director <br /> Employer Name/Occupation/Profession/Title North Carolina Memorial Hasp, <br /> Mannin. Drive, Cha.el Hill North Carolina 27514 <br /> Home Address 901 Kings Mill Road, Cha■el Hill N.C. 27514 <br /> Telephone: Home 929-4501 - Business 966-5111 <br /> 2. Sex: X Male Female <br /> 3. Age Group: 18-34 X 35-44 45-64 65 4 Over <br /> 4. Family Income: Less Than $10,000 $15,000424.;999 <br /> $20,000-$24,9.99 X $25,000 or more <br /> 5. Race: X White Nonwhite <br /> 6. Education 12 years or less 13-16 years X 16 years or more <br /> Academic Degrees (e,g., B.A., B.S,, M.A., etc.) B.A. , M.B.A. <br /> 7. Do you have any physical handicaps or disabilities? . No <br /> If "yes", please describe: <br /> 8. Are you being nominated to represent law income and/or disadvantaged? <br /> No <br /> 9. List Major Organizational Memberships: <br /> - American Hospital Association <br /> - American Colle e of Hospital Administrators <br /> (over) <br />