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CITIZEN VOLUNTEER APPLICATION FOR COUNTY BOARDS, COMMITTEES & COMMISSIONS Name Date Home Address City State Zip Code Home Telephone Number FAX E-Mail Address Election District: District 1 District 2 District 3 District 4 District Present Employer Employer Address City State Zip Code Business Telephone Number FAX Which Address is Preferred for Mailings? Home Office Optional Information Which May Prove Helpful: Occupation Former Occupation, If Retired Education: High School Year College/Technical School Year Graduate School Year Military Service Years Degrees/Other Past Board, Commission, and/or Committee Assignments Professional, Civic, or Other Activities Please state below your interest and/or reason to seek appointment by the Board of Supervisors and any special qualities that qualify you for this appointment. ---PAGE BREAK--- Page Two Do you have a family member who is currently employed by the county government, organization or institution over which the Board/Commission for which you are seeking appointment will oversee/interact? If yes, please explain. Do you have a business relationship with the county government, organization or institution over which the Board/Commission for which you are seeking appointment will oversee/interact? I am interested in and willing to serve on the following Board(s), Commission(s), or Committee(s). Please list in order of preference. APPOINTED BY THE BOARD OF SUPERVISORS: Planning Commission Public Library Board of Trustees Hope Board Economic Development Authority Museum Advisory Board Piedmont Senior Resources Board Recycling Taskforce Social Services Board Southside Community College Board Water & Sewer Advisory Board Workforce Investment Board Other(s) APPOINTED BY CIRCUIT COURT: Electoral Board Board of Zoning Appeals By submitting this application to the County of Cumberland, I hereby certify that all information contained herein is true and complete and I consent to the dissemination of this document to the general public. Signature Date Please Return Application To: Cumberland County Administrator’s Office Post Office Box 110 1 Courthouse Circle Cumberland, Virginia 23040 Tel: [PHONE REDACTED] FAX: [PHONE REDACTED] e-mail: [EMAIL REDACTED] NOTE: This application will be retained on file in the Cumberland County Administrator’s Office through December 31 of the year submitted. If you wish to be considered for future appointments by the Board of Supervisors, please file an application annually with the County Administrator’s Office. Thank you. May 2020 SIGN