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'2£-r rye a�,�5�,�My�•[� y°�� Y.-14'.1,;l [} 3+fr"�'C�rs4. ��..,itt'�'f ,�,,,yt'."rt '-'_. '"d�i • �-���'li''+�law.».d'`"i� $5.�. <br /> ;''''''... '' .w v..r''.+.'"SST S 74:'''.� .., t O ty, ;4:' S !"C', � .r.-� '". } '2"44,314` '^Y r `x n,• <br /> PL:f. _ i-t_..•. [ ..> +.r.'t>N' 4 •,•:,:.-.,........-,y, <br /> +" - i `L:.` `'jgai.1` w: Y <br /> 1jj <br /> flame � I �,^ r - ,� srlt ~rC as .a.15-14,L. <br /> gailin9 Addre5'1s. .' . Tip <br /> ,u <br /> - II r► 4 i .I.. ..i .+. gusiness - <br /> 3 i. <br /> Tel Indian ,..» - .: r <br /> Ethnic Background: glae .� - - " Age: .3--4".--' . .. :.. <br /> Sex: i1ale - '_ �exaa l4, . -� . . -- - --�- - <br /> Education: ( �ighest) •y �- ' - _ .4 1 ..: -t,' e.. <br /> a <br /> Occupation: •A <br /> Community Interests and ACtiVi ies. _�_. _... <br /> -- 11 i 1 <br /> unship da you reside? - <br /> In Which t -. -a , <br /> {not a plicable in same ir�stances� - <br /> r geed in servir►9 an: <br /> I. <br /> amiinte _ _ _ _ <br /> i si gnature /i! . <br /> Date: St� <br /> , , _ <br /> Clerk VI the Board of <br /> County C4mn! ssaners <br /> getum 4 106 I. ii,1 ar'at 'Leine .... <br /> - i{i'llsborou9hh tiC 27 <br /> • <br /> - <br /> , . <br />