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014 <br />COUNTY OF LEE <br />APPLICATION TO SERVE ON BOARDS//COMMISSIONS <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 />_ Juvenile Crime Prevention Council <br />— Fire Advisory Board <br />_ Board of Health <br />Mental Health Board <br />NAME: <br />MAILING ADDRESS: j <br />HOME PHONE:V?'yhi `7, <br />YEARS LIVING IN <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 />Industrial Facilities & Pollution Control <br />Financing Authority <br />Rest Home -Nursing Home Advisory Board (cannot have <br />a relative residing in a facility) <br />WORK PHONE: <br />LEE COUNTY: DISTRICT YOU LIVE IN: 7,v,�,,/ -T�,v/ <br />MALE: — FEMALE: -)/ WHITE: BLACK: HISPANIC: NATIVE AMERICAN <br />(In ormation for the purpose of assuring a cross section of the community) OTHER <br />EMPLOYER: ;a <br />OCCUPATION: <br />OTHER MUNICIPAL OR COUNTY BOARDS/COMMITTEES ON WHICH YOU ARE SERVING: <br />(Generally, the Board of Commissioners desires to broaden participation onBoards/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 />Are you related to anyone currently serving on any County board/commissign? If yes, please state name and board they serve on <br />PLEASE LIST THREE (3) LOCAL PERSONAL REFERENCES AND PHONE NUMBERS: <br />v / <br />G� <br />3. :tom - o`er 77f f' <br />REASON(S) YOU WISH TO SERVE <br />(Attach additional page if re space is neede) 1 `O 9�• �<, <br />n <br />d <br />SIGNATURE: _ � �4,- <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 />R ITIVED <br />JUL, 2016 <br />✓, <br />