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013 <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, (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 />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 />NAME: 7A 1V c9:-TTZ_ .7 C O-"`7` i3 3Z <br />MAILING ADDRESS: PSS40 x'u CAR V,1A1A41, Q 2 <br />HOME PHONE: i (D ' 7bc)0 WORK PHONE: 919-4,)x} -7 , 8D E-MAIL30-( <br />YEARS LIVING IN11 ne{- <br />LEE COUNTY: a 3 DISTRICT YOU LIVE IN:,_).A t2 C� 0 <br />MALE: _ FEMALE: WHITE: ✓ BLACK: _ HISPANIC: _ NATIVE AME AN OTHER <br />(Information for the purpose of assuring a cross section of the community) <br />EMPLOYER: P; I R <br />OCCUPATION: Y e_-Vk r e - <br />OTHER MUNICIPAL OR COUNTY BOARDS/COMMITTEES ON WHICH YOU ARE SERVING: <br />NIR <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 />Are you related to anyone currently serving on any County board/commission? If yes, please state name and board they serve on <br />PLEASE LIST THREE (3) LOCAL PERSONAL REFERENCES AND PHONE NUMBERS: <br />1.'Dy^. d� t-) k r ina iAck LtYln q 19 - `7'7 q — &S %� <br />2. Ms : J \,k CA I -A W 0 ry_� cz�— l< 9 i C1 - <br />3. W\3V S . V9. 1 <br />REASON(S) YOU WISH TO SERVE, <br />if more space is needid) <br />SIGNATU <br />E! <br />DATE: /J_ - o — —4 y / �- <br />NOTE: ALL TAXES MUST BE PAID IN FULL BEFORE BEING CONSIDERED FOR APPOINTMENT <br />THIS APPLICATION IS CONSIDERED A PUBLIC RECORD <br />RECEIVED <br />DEC �. 5 20116 <br />BY: <br />