Orange County NC Website
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/ 3 <br /> FOR OFFICE USE ONLY <br /> 19 62 P. I o F 3 4%,,.)n C. p;Gke4-t <br /> VOLUNTEER APPLICATION <br /> ORANGE COUNTY ADVISORY BOARDS AND COMMISSIONS <br /> If you are an Orange County resident, at least 18 years old, and willing to vrE:9 expertise to your community, please complete this application and return tI <br /> Orange County Commissioners Office P.O. Box 8181 x002 Hillsborough, NC 27278 Phone (919)245-2125;245-2129; 245-2130; 732-8181 !f <br /> Fax: (919) 644.0246 - Email: npociga @co.orange.nc. <br /> NAME: ��-Q,c,<t7(, e,, LCL--( <br /> HOME ADDRESS: /0 <br /> CITY: � � , . [�_ Zip Code: <br /> PHONE: (Day) L9tj) li.9-f S' (Evening/late) �9�9��d9-eq6 S- (Fax) <br /> EMAIL: ,�.c <br /> PLACE OF EMPLOYMENT: t p / JOB TITLE: <br /> IN ORDER TO ASSURE COUNTYWIDE REPRESENTATION.PLEASE INDICATE YOUR TOWNSHIP <br /> OF RESIDENCE: <br /> O Bingham 'O Cheeks O Hillsborough O Eno GA Chapel Hill O Little River- O-CedarGrove- <br /> IN ADDITION, PLEASE INDICATE IF YOU LIVE IN ONE OF THE FOLLOWING AREAS: <br /> O Joint Planning Area O Extraterritorial Area O Transition Area <br /> WE ASK YOUR HELP IN ASSURING DIVERSITY OF MEMBERSHIP BY AGE,GENDER AND RACE, <br /> BY ANSWERING THE FOLLOWING QUESTIONS: O Male C)q Female <br /> ETHNIC BACKGROUND: O African American W Caucasian O Hispanic 0 Native American <br /> O Other DATE OF BIRTH: //_j-*6- <br /> PLEASE LIST(IN ORDER OF PREFERENCE)THE BOARDS/COMMISSIONS ON WHICH YOU <br /> WOULD BE WILLING TO SERVE. <br /> 1. Ju.fctr .a _,. - C 2. �C� C�r7-. G� 3. l b yyl nttiS4ri ri l dl�a <br /> rntn <br /> WORK EXPERIENCE: <br /> VOLUNTEER EXPERIENCE: m <br /> - `o n <br />