TOWN OF ALTAVISTA
Application for Boards, Commissions, and Committees
The Altavista Town Council is accepting applications for seats on Town Boards, Commissions, and Committees
with qualified and interested Town residents who have expressed a desire to serve the community in a special
way. An appointment to a Town body should receive serious consideration by applicants as the work to
be accomplished will help determine the future direction of our community. You will be contacted before any
action is taken by Town Council. Incumbents whose terms expire may be considered for reappointment
unless they indicate non-interest, preferably in writing. No person is required to supply any of the information
requested in order to be considered, and applicants should be aware that all such information supplied shall
be available to the general public or press for a period of three (3) years, after which time it will be purged
from town records. (Please type or print the requested information clearly.)
Full Name: _______________________________________________________________________________
Preferred Name: __________________________________________________________________________
Physical Residential Address: ________________________________________________________________
Postal Mailing Address: ____________________________________________________________________
Email Address: _______________________________________________________________
Home telephone: ______________________ Work telephone: __________________________
Cell telephone: ________________________ Facsimile (FAX): _________________________
Occupation: ____________________________________________________________________________
Retired: _______ Yes _______ No
Education or training:
________________________________________________________________________________________
________________________________________________________________________________________
Professional and Community activities:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What are your specific qualifications as they relate to the Boards, Commissions or Committees you have
requested to serve on? What will you bring to the table to make that Board, Commission or Committee serve
the Town citizens better:
________________________________________________________________________________________
____________________________________________________________________________________
Have you ever been convicted of a felony? If so, please provide details (including date, court, crime and
sentence):
________________________________________________________________________________________
_______________________________________________________________________________________
I, the undersigned applicant, do hereby certify that the above information given above by me for the purposes
stated herein, is correct to the best of my knowledge.
Si
gnature: _____________________________________ Date: ______________________
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