Fillable Application For Boards Commissions Committees (Pender County Government)

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Application For Boards Commissions Committees (Pender County Government)

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P
A
A
o
P
ENDER
A
pplication
A
ppointees to
P
o
f age. Please
A
PPLICANT
I
Last Name
Physical Addres
s
City
Mailin
g
Address
City
Home Phone
Fax Number
Board Interest(
s
How lon
g
have
y
EDUCATION
High School
From
College
From
Other
From
EMPLOYME
N
Current Employ
m
Responsibili
t
Previous Emplo
y
Previous Emplo
y
Previous Emplo
y
COMMUNIT
Y
Please list curre
n
COUNT
Y
for Appoin
t
P
ender County
complete this
a
I
NFORMATI
O
s
(if different fro
m
)
y
ou been a resid
To
To
To
N
T HISTORY
m
ent
t
ies
y
ment
y
ment
y
ment
Y
INVOLVEM
E
n
t and past me
m
Y
t
ment to B
o
Boards/Comm
a
pplication an
d
O
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m
above)
ent of Pender C
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Did you
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gr
Did you
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m
bership in civic
o
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issions/Commi
t
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return to: Pe
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First
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State
Work Phone
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unty?
Loca
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aduate? YES
Loca
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aduate? YES
Loca
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aduate? YES
o
r other or
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issions/C
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tees must be
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der County M
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t
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t
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Job
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Job
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Job
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a
tions and office
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mmittees
a Pender Cou
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Degree
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, PO Box 5, B
u
M.I.
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ZIP
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ail Address 1
m
ail Address 2
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must be at l
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rgaw, NC 28
4
Date
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it #
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ast 18 years
4
25.
Pender County
Application for Appointment to Boards/Commissions/Committees
Revised 12/2010
Have you ever served or are you currently a member of any Pender County or other local government board/commission/committee?
YES NO If yes, explain (including length of service).
State reasons why you feel qualified for this appointment(s):
MILITARY SERVICE
Branch
From To
Rank at Discharge Type of Discharge (optional)
CONFLICTS OF INTEREST
Are you aware of any legal, ethical or personal conflict of interest by serving as a member of this Pender County
board/commission/committee?
YES NO If yes, explain.
Is any member of your family employed by Pender County, or currently serving on a board/committee/commission appointed by or
affiliated with Pender County?
YES NO If yes, list family member name(s) and position/board or committee(s).
Please add any additional information you would like to share supporting your interest and qualifications for this appointment.
DISCLAIMER AND SIGNATURE
NOTE: This information will be used by the Pender County Board of Commissioners in making appointments to Pender County
Boards/Commissions/Committees. In the event you are appointed, it may be used as a news release to identify you to the community.
This application is considered a public record.
Signature Date
Are you or any member of your family employed by Pender County, or currently serving on any Boards/Committee/Commission
appointed by or affiliated with Pender County?
Submit Form by Email
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Application For Boards Commissions Committees (Pender County Government)

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Completed 25 July 2020

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