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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 _ Jury Commission <br />Agriculture Advisory Board Library Board of Trustees <br />Americans with Disabilities Act (ADA) __p/ Parks & Recreation Commission <br />Board of Adjustments (Lee County) _ Planning Board (Lee County) <br />_ Board of Adjustments (Sanford) _ Planning Board (Sanford) <br />Board of Equalization & Review _ Senior Services Advisory Board <br />Cemetery Board of Trustees _ Social Services Board <br />CCCC Board of Trustees _ Transportation Advisory Board (COLTS) <br />Juvenile Crime Prevention Council Industrial Facilities & Pollution Control <br />Fire Advisory Board Financing Authority <br />Board of Health _ Rest Home-Nursing Home Advisory Board (cannot have <br />Mental Health Board a relative residing in a facility) <br />NAME: C1 GJ-Gizl T <br />MAILING ADDRESS: pGA_ 'k)r,\j � S $JL 3 <br />HOME PHONE(C 35_-,)O�' WORK PHONE:E-MAIL ,�: Zt y %;. cz,— <br />YEARS LIVING INr <br />LEE COUNTY: DISTRICT YOU LIVE IN: JAS <br />MALE: \FEMALE: —WHITE: _ BLACK: t'HISPANIC: _ NATIVE AMERICAN _ OTHER _ <br />(Information for the purpose of assuring a cross section of the community) <br />EMPLOYER: <br />OCCUPATION: <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 />Are you relWed to anyone currentl 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 />2. �� P_1. <br />3. maria <br />REASON(S) YOU WISH TO SERVE UD sk xkN 'Al Vic,_ <br />(Attach�'d�itgio_�nalpe if e s e is ne ded) <br />SIGNATURE: DATE:2>0 <br />NOTE: ALL TAXES MUST BE PAID IN FULL BEFORE BEING CONSID RED FOR APPOIV D <br />THIS APPLICATION IS CONSIDERED A PUBLIC RECORD OCT I <br />CT -A2016 <br />7BY- <br />Ly <br />1' <br />