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Dec.21. 2010 5.13PM CENTRAL CAROLINA HOSPITAL <br />— No. 2582 P. 2 <br />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, <br />please complete the form below and mail to Clerk to the Board, Lee County Government Center, PO Box 1968, <br />Sanford, NC, 27331 -1968 or fax to 718 -4631. 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 />_ Environmental Affairs Board <br />Board of Health <br />Industrial Facilities & Pollution Centro <br />NAME: <br />Jury Commission <br />Library Hoard of Trustees <br />Mid-Carohna Workforce Development Board <br />Parks & Recreation Commission <br />_ Planning Board (Lee County) <br />_ Planning Board (Sanford) <br />Rest Home- Nursing Home Advisory Board <br />Senior Services Advisory Board <br />_ Social Services Board <br />Transportation Advisory Board <br />Juvenile Crime Prevention Council <br />Criminal Justice Partnership Advisory Board <br />Financing Auth- <br />I Cb'DU - -S bzAi5 <br />MAILING ADD RESS: 2, 1 l _D�6lew(1ee L4, I _ <br />• HOME PHONE: 776L *7 WORKPHONE: - 771 E -MAIL bou6-, �DdLls( <br />YEARS LIVING IN <br />LEE COUNTY: DISTRICT YOU LIVE IN: <br />M <br />MALE: _ ✓FEMALE: — WHITE' L HISPANIC: — NATIVE AMERICAN OTHER <br />/ (Infou for the purpose of assuring a cross soctlon of the community) <br />EMPLOYER: if- Bt �/ �I C O fl GIA f-I 0 �:0 44- <br />OCCUPATION: /4 4-4 ff 0.,1, r ti iS lklf-T - a <br />OTHER MUNICIPAL OR COUNTY BOARDS /COMMITTEES ON WHICH YOU ARE SERVING: <br />10 o -It e_. <br />(Generally, the Board of Commissioners desires lob fogdon paolclpahon on BoarduCommissions for as much ceizen involvement <br />as possible: therefore per Board policy, appolmeos can sorvo on no more the [We (2) BOWSICommissfons at a lime. <br />PLEASE LIST THREE (3) LOCAL PERSONAL REFERENCES AND PHONE NUMBERS: <br />ltitc- o 77�1-�oZ� <br />2 <br />3. <br />ue7f,e.c l�i. <br />SIGNATURE: / / DATE: <br />• <br />DEC 2 8 2U10 <br />