Fillable NELSON COUNTY BOARDS AND COMMISSIONS APPLICATION FORM Subject: (Nelson County)

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NELSON COUNTY BOARDS AND COMMISSIONS APPLICATION FORM Subject: (Nelson County)

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NELSON COUNTY BOARDS AND COMMISSIONS APPLICATION FORM
Subject: Appointments - Statement of Interest Form
Completing this form is one way to indicate your interest in being considered for appointment to some of
the Boards, Commissions and Committees appointed by the Board of Supervisors. All appointments
remain at the discretion of the Board of Supervisors.
Please complete and mail this form to:
Nelson County Board of Supervisors
Attention: Stephen A. Carter, Clerk of Board
Post Office Box 336
Lovingston, VA 22949
or fax to (434) 263-7004
____________________________________________________________________________________
Date _______________
Mr. ______ Mrs. ______ Ms. _______
Name: ___________________________________
List a maximum of three (3) Boards on which you are interested in serving.
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
Home Address:
____________________________________________________________________________________
____________________________________________________________________________________
Occupation: ________________________ Employed by: ______________________
Home Phone No.: ____________________ Business Phone No.:_________________
Fax No.: ____________________________ E-Mail Address: ___________________
Do you live in Nelson County? Yes ___ No ___
Are you currently a member of a County Board, Commission, Committee or Authority? Yes ___ No ___
If yes, list the Board(s):
____________________________________________________________________________________
____________________________________________________________________________________
What talent(s) and/or experience can you bring to the Board(s)?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What do you feel you can contribute to the Board(s) and to the community that may not be evident from
information already on this form?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please use this space for any additional information you would like to provide:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
A resume or separate sheet with additional information may be included.
ATTENDANCE REQUIREMENTS
Section 2-153, Absences, Chapter 2, Administration, Article V. Appointments for Boards and
Commissions of the Nelson County Code, an appointee of the Board of Supervisors who either (a) fails,
during a calendar year, to attend seventy-five percent of the regular meetings of the board or commission
of which he/she is a member, or (b) is absent for three consecutive regular meetings, shall be deemed to
have tendered his/her resignation from such position. The Board of Supervisors may accept such
resignation by appointing another person to fill the position.
In light of the above, will you be able to attend at least 75% of the regular meetings of the boards to which
you may be appointed?
Yes ___ No ___
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NELSON COUNTY BOARDS AND COMMISSIONS APPLICATION FORM Subject: (Nelson County)

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Completed 22 January 2021

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