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2. Contact Information
4. Name*
5. District*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address
18. Place of Employment
19. Occupation
21. Educational Background
    Educational Background
23. Committees of Interest (please mark all that apply)

    1. Anchor Commission
    2. Blue Ridge Library Board of Directors
    3. Board of Equalization
    4. Building Board of Appeals
    5. Community Policy and Management Team
    6. Dan River Alcohol Safety Action Program
    7. Department of Social Services
    8. Economic Development Authority
    9. Patrick & Henry Community College Board of Directors

    1. Piedmont Community Services
    2. Planning Commission
    3. Public Service Authority
    4. Solid Waste Committee
    5. Southern Area Agency on Aging
    6. Stormwater Board of Appeals
    7. Tourism Advisory Council
    8. West Piedmont Planning District Commission
25. Why do you wish to serve the County in this capacity?
27. Do you have an area of expertise that you believe would be beneficial?
29. Signature*
30. Date*
32. Thank you for your interest in appointment to the County's Advisory Boards and Commissions.
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

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