C:\Users\Juan\Documents\Web Development\County Website Downloads\Contracts\PFR-Review-Panel-Member-Application.doc
APPLICATION FOR APPOINTMENT
LEE COUNTY DEPARTMENT OF HUMAN SERVICES
PARTNERING FOR RESULTS PROPOSAL REVIEW PANEL
The information will be used to screen applications. Please complete each blank on all pages of the questionnaire
and return it to the office indicated on the front of this form. Please type or use black ink.
Name LAST FIRST MIDDLE OR MAIDEN
Residence Address STREET CITY ZIP CODE
Business Address STREET CITY ZIP CODE
Mailing Address STREET or P.O. BOX CITY ZIP CODE
Contact Information: TELEPHONE FAX E-MAIL
Please specify the preferred method of contact: Mail Fax E-Mail
1. It is desired to have minority participation on this Committee. Please indicate whether you are a minority.
Check one (Optional) Minority Non-Minority
2. How long have you lived in Lee County?
3. Commission District:
District 1 Commissioner Manning
District 2 Commissioner Pendergrass
District 3 Commissioner Kiker
District 4 Commissioner Hamman
District 5 Commissioner Mann
4. Highest Level of Education attained:
5. Occupation:
(plea
se indicate if attending school/college)
6. List your most recent two employers (if applicable).
EMPLOYER TYPE OF BUSINESS POSITION DATES
7. Briefly explain any volunteer activities in which you are involved.
