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35 <br />FOR OFFICE USE ONLY <br />8123191 R 1 0? 2 R u+he k. M eisel <br />VOLUNTEER APPLICATION <br />ORANGE COUNTY BOARDS AND COMMISSIONS <br />If you are an Orange County resident, at least 18 years old, and willing to volunteer your <br />time and expertise to your community, please complete this application and return to: <br />NAME: K C? <br />Orange County Commissioners' Office <br />P.O. Box 8181 ' D <br />Hillsborough, NC 27278 <br />Phone (919) 732-8181; 688-7331; 968-4501; 227-2031 AUb 2 3 <br />Ext. 2125, 2129 or 2130 • Fax: (919) 644-0246 <br />Al /4?1 i <br /> <br />???©? y? <br />HOME ADDRESS: /0"a <br />CITY: <br />Zip Code: a -7 s? <br />TELEPHONE: (H) Y ` 44L (W) (Fax) <br />EMAIL: <br />PLACE OF EMPLOYMENT: JOB TITLE: rnet? _ <br />IN ORDER TO ASSURE COUNTYWIDE REPRESENTATION PLEASE INDICATE YOUR <br />TOWNSHIP OF RESIDENCE: Bingham Cheeks <br />Hillsborough Eno <br />Chapel Hill ? Little River <br />Cedar Grove <br />IN ADDITION, PLEASE IN XCATE IF YOU LIVE IN ONE OF THE FOLLOWING AREAS: <br />Joint Planning Area V Extraterritorial Area Transition Area <br />WE ASK YOUR HELP IN ASSURING DIVERSITY OF MEMBERSHIP BY AGE, GENDER <br />AND RACE, BY ANSWERING THE FOLLOWING QUESTIONS: <br />Male - ETHNIC BACKGROUND:- <br />Female African American Hispanic <br />Caucasian ? Other <br />Native American <br />DATE OF BIRTH: 1 09 <br />PLEASE LIST (IN ORDER OF -PREFERENCE) JHE BOARDS/COMMISSIONS ON WHICH <br />YOU WOULD WILLING TMS7v F"ft''o d6 v <br />1. -2 G'ves jAl 4 e; {- Crnc ? <br />3. ?- ?? furo F4 °?` ?'ldt4 sc ci.l'7& <br />1l¢ cdtfed k??a-.' d