HENRY COUNTY BOARD OF SUPERVISORS
NOMINEE INFORMATION FORM
Name:_________________________________ Phone:_______________
Address: ________________________________________________________
_________________________________________________________________
Voting District: ____________________ Employer: _________________
Commission(s) or Board(s) on which you are interested in serving:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please list your background, training, or experience which you feel
would contribute to this group (you may attach a resume):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________
Have you ever worked for the Board/Commission on which you are
interested in serving? Yes No
If so, when? _______________________________
__________________________________ ___________________________
Signature Date
Please return to:
Tim Hall
Henry County Administrator
P. O. Box 7
Collinsville, Virginia 24078
