Agenda - 12-02-2002-9g - Laserfiche WebLink

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~~ FOR OFFICE USE ONLY a VOLUNTEER APPLICATION ORANGE COUNTY ADVISORY BOARDS ANO COMMISSIONS If you are an Orange County resident, at least 18 years o[d, and willing;to volunteer your time and expertise to your community, please complete this application and rotur~;;~.-: = ~ _. •... . • ~ ~:. Orange County Commissioners' Office P.O. Box 8181 • Hillsborough, NC 27278 ~~i ~ ) . Phone (919) 245-2125; 245-2129; ?.5..2150; 752-8181 . Fax: (919) 644-0246 • Email: nmartin~co.oranye.nc.us NAME: s c ?l.~mt~rs _ t..._. ... _ ._.. HOME ADDRESS: /OSi.d /,c~o~ CITY:~~.•-r`~~~/U.C: - T.IIp Code: .Q 9S`~G PHONE: (Day) .~9i_ 9) 7~'3~ (gvsning/late) 9/~-77oP' (Fax) . EMAIL: . PLACE OF EMPLOYMENT: .~.-~ ~ JOB TITLE: :~ ~E,N•rx~e.u .~ / ~~~ IN ORDER TO ASSURE-000NTYWIDE REPRESENTATION PLEASE INDICATE YOUR TOWNSHIP OF RESIDENCE: ^ Bingham ^ Cheeks ^ Hillsborough ^ Eno Fd Chapei HIII ^ Ltttie River ^ Cedar Gra~re IN ADDITION, PLEASE INDICATE IF YOU LIVE 1N ONE OF THE FOLLOWING AREAS: ^ Jolnt Planning Area ^ Extraterritorial Area ^ Transition An:a WE ASK YOUR HELP IN ASSURING DIVERSITY OF MEMBERSHIP BY AGl:, GENDER AND RACE, BY ANSWERING THE FOLLOWING QUESTIONS: ~1 Male ^ Female ETHNIC BACKGROUND: ^ African American ®Caucasian D Hispanic ^ Native American - -. .. _, .. ^ Other DATE OF BIRTH: _ f/~~/fir ~~ PLEASE LIST (IN ORDER OF PREFERENCE) THE BOARDS/COMMISSIONS ON WHICH YOU WOULD BE WILLING TO SEJZVE. WORK EXPERIENCE: r.,,~/~~4c ~ ~ ~ ~ ~~~~~ r f~-~.. ~ f~ . ~ ,~ VOLUNTEER EXPERIENCE; ..~?