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044 <br />COUNTY OF LEE <br />APPLICATION TO SERVE ON BOARDSHCOMMISS IONS <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, (408 Summit Drive), PO Box 1968, Sanford, NC, 27331- <br />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 />_ Sanford -Lee Co. Partnership for Prosperity <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: NJ/ 7 jyG& �., ' ;� 4+y,,,, - <br />HOME <br />, -HOME PHONE: ��el •� °1z -DyD,Z WORK PHONE:E-MAIL , �'�3� j�X� <br />YEARS LIVING IN T <br />LEE COUNTY: �, $ DISTRICT YOU LIVE IN: <br />MALE: FEMALE: _ WHITE: K BLACK: _ HISPANIC: _ NATIVE AMERICAN _ OTHER _ <br />(Information for the purpose of assuring a cross section of the community) <br />EMPLOYER: LEc <br />OCCUPATION: V Z> -A Cb Acr,4 <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 PERSONAL REFERENCES AND PHONE NUMBERS: <br />e-, "7'/e7- 77 — 939/ <br />2. lV fiV/d9 eA P <. A ^) <br />3. <br />REASON(S) YOU WISH TO SERVE <br />--/L- Z pi• -1G sr< +�J- r,-1 &- ci <br />(A ch additional page if more space is needed) G n. c. _j T <br />SIGNAT <br />f� •777 - 9S ss <br />d e �4cr a 2e <br />S /AW E' 376 •u a -JQ X Ta R'r <br />DATE: <br />NOTE: ALL TAXES MUST BE PAID IN FULL BEFORE BEING CONSIDERED FOR APPOINTMENT <br />THIS APPLICATION IS CONSIDERED A PUBLIC RECORD <br />DEC -- 7 2015 <br />