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TOWN OF OLD LYME 52 LYME STREET OLD (Town of Old Lyme)

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Qualifications for appointment:_______________________________________________________
______________________________________________________________________________________
TOWN OF OLD LYME
52 LYME STREET
OLD LYME, CT 06371
phone: 860 434 1605
fax: 860 434 1400
e-mail: selectmansoffice@oldlyme-ct.gov
Date:___________________________
Request for appointment to:___________________________________________________________
Board/Commission
Name:_______________________________________________ Phone #:_________________
Street Address: _____________________________________________________________________
Mailing Address (if different): _________________________________________________________
e-mail address: __________________________________ # Years Resident of Old Lyme:______
Registered Voter in Old Lyme:
Yes
No
Political Party (Circle one): Democrat Republican Unaffiliated
Previous Service in Old Lyme:_________________________________________________________
______________________________________________________________________________________
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TOWN OF OLD LYME 52 LYME STREET OLD (Town of Old Lyme)

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Completed 14 July 2020

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