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CITIZEN PROFILE FOR APPOINTMENT VOLUNTEER BOARDS, COMMITTEES, COMMISSIONS, & AUTHORITIES Title: Name: Date: Address: Phone: Email: Registered Voter: □ Yes No I AM INTERESTED IN SERVING ON THE FOLLOWING: (Check all that apply) Airport Authority Board of Elections and Voter Registration Board of Equalization Board of Health Board of Assessors Department of Family and Children Services (DFCS) Board Development Authority Gordon County Public Facilities Authority Gordon-Floyd Development Authority Highland Rivers Community Service Board Historic Preservation Commission Historical Society Hospital Authority Library Board Limestone Valley Resource, Conservation, and Development Agency Northwest Georgia Region I Emergency Medical Services Coordinating Council Northwest Georgia Regional Commission Planning & Zoning Commission Region I Behavioral Health and Developmental Disabilities Advisory Council Tallatoona Community Action Partnership Place of Employment: Title: Education: High School □ Two-Year Degree □ Four-Year Degree □ Post Graduate Degree Previous Community Involvement: Please return completed form to: County Clerk - Gordon County Board of Commissioners P.O. Box 580 Calhoun, Georgia 30701 [EMAIL REDACTED] ---PAGE BREAK--- CITIZEN PROFILE FOR APPOINTMENT VOLUNTEER BOARDS, COMMITTEES, COMMISSIONS, & AUTHORITIES Applicant Name: Are you at least 18 years of age? Yes No Are you a resident of Gordon County? Yes No Have you ever been convicted of a felony? Yes No Are you willing to attend training relative to the responsibilities of the Board Membership, as provided by Gordon County? Yes No Please summarize any prior experience you possess which would be applicable to the appointment you are requesting: Please summarize why you wish to serve in the appointment you are requesting: Please return completed form to: County Clerk - Gordon County Board of Commissioners P.O. Box 580 Calhoun, Georgia 30701 [EMAIL REDACTED]