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f3 <br />COUNTY OF LEE <br />APPLICATION TO SERVE ON BOARDSHCOMMISSIONS <br />If you are a Lee County citizen interested in serving as a member of one of the County's Advisory Boards, please <br />complete the form below and mail to Clerk to the Board, Lee County Government Center, PO Box 1968, Sanford, <br />NC, 27331 -1968 or fax to 919 - 718 -4623. YOU MUST BE A RESIDENT OF LEE COUNTY TO APPLY. <br />BOARDS AND COMMISSIONS <br />_ Sanford -Lee County Airport Authority <br />_ Agriculture Advisory Board <br />_ Americans with Disabilities Act (ADA) <br />_ Board of Adjustments (Lee County) <br />Board of Adjustments (Sanford) <br />_ Board of Equalization & Review <br />_ Cemetery Board of Trustees <br />CCCC Board of Trustees <br />Economic Development Corp. <br />Fire Advisory Board <br />Board of Health <br />_ Mental Health Board <br />NAME: <br />Jury Commission <br />_ Library Board of Trustees <br />Parks & Recreation Commission <br />Planning Board (Lee County) <br />_ Planning Board (Sanford) <br />Senior Services Advisory Board <br />Social Services Board <br />Transportation Advisory Board (COLTS) <br />Juvenile Crime Prevention Council <br />Industrial Facilities & Pollution Control <br />Financing Authority <br />_ Rest Home - Nursing Home Advisory Board (cannot have <br />. a relative residing in a facility) <br />MAILING ADDRESS: �'�lD --� �� W �T III %I/r= <br />Z� 1_, V � �j <br />HOME PHONE: `�I � I�CI�I�N <br />N. ORK PHONE: C '�I c6t -MAIL V 1 KeY k?@ <br />YEARS LIVING IN 110 <br />1. CUYN <br />LEE COUNTY: DISTRICT YOU LIVE IN: 5 1 <br />1 <br />MALE: _ FEMALE: _ ✓WHITE: _ BLACK: _ HISPANIC: ✓_ NATIVE AMERICAN OTHER _ <br />(Information for the purpose of assuring a cross section of the community) <br />EMPLOYER: <br />OCCUPATION s st_ <br />OTHER MUNICIPAL OR COUNTY BOARDS /COMMITTEES ON WHICH YOU ARE SERVING: <br />(Generally, the Board of Commissioners desires to broaden participation on Boards /Commissions for as much citizen involvement <br />as possible: therefore per Board policy, appointees can serve on no more than two (2) Boards /Commissions at a time. <br />PLEASE LIST THREE (3) LOCAL PERSONA � REFERENCES AND PHONE NUMBERS: <br />1. eirm 1 iii rvp m <br />REASONS YO11 WISH TO SERVE I Y� fi _ICJ i1�� <br />(Attach additional p e if more spac ' eeded) <br />SIGNATURE: l DATE: � — <br />NOTE: ALL TAXES MUST BE PAID IN FULL BEFORE BEING CONSIDERED FOR APPOINTMENT <br />JAN 2 7 101�� <br />vfi\ <br />