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COUNTY OF ALBEMARLE

APPLICATION TO SERVE ON BOARD/COMMISSION/COMMITTEE
Date of Application: 6/28/2016

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(* indicates a REQUIRED field)
*Board/ Commission/ Committee:   
Please enter name of Board/ Commission/ Committee if not found on the list above
 
  
If this Board/ Commission/ Committee has specific membership representation, for example, PTO member, business community member, etc, please list your affiliation (Please list all that apply)

(Separate lines or paragraphs with semicolons ";" to improve readability)
   
 (Maximum 300 characters)
Please review the applicable Board/ Commission/ Committee information page to see if there are any specific
membership representation or affiliation requirements. If it is required, you will be prompted to enter this information.
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*Applicant:     
*Home Phone: - -     (AAA-NNN-NNNN)
Email Address:
Please note if you do not provide an email address you will not get a confirmation of this application.
 
  
*Full Home Address:   

,   (NNNNN)
*Magisterial District in which your home residence is located:   

*Employment Status:    
 Employment information below is required only if you are currently employed or self-employed.
Primary Employer:    
Phone: - -     (AAA-NNN-NNNN)
Business Address:   

,    (NNNNN)
Occupation/Title:   
Date of Employment:        (MM/MM/YYYY)

*Years Resident in Albemarle County:    (NN)
Previous Residence (if applicable):
  
Spouse's Name (if applicable)   
Number of Children (if applicable)    (NN)

*Education (Degree(s) and Graduation Date(s)):
(Separate lines or paragraphs with semicolons ";" to improve readability)
  
 ((Maximum 300 characters)
*Memberships in Fraternal, Business, Church and/or Social Groups:
(Separate lines or paragraphs with semicolons ";" to improve readability)
  
 ((Maximum 300 characters)
*Public, Civic and Charitable Office and/or Other Activities or Interests:
(Separate lines or paragraphs with semicolons ";" to improve readability)
  
 ((Maximum 300 characters)
*Reason(s) for Wishing to Serve on this Board/ Commission/ Committee:
(Separate lines or paragraphs with semicolons ";" to improve readability)
 
  
 ((Maximum 300 characters)
How did you hear about this vacancy?
(Separate lines or paragraphs with semicolons ";" to improve readability)
  
 ((Maximum 100 characters)

Click here to send an email with your supplementary document. Please attach the file to the email BEFORE you submit this application. If "B/C Application Supplementary Document" does not automatically appear in the subject field, please enter it manually.

PLEASE RESTRICT ANY ATTACHMENTS TO ONE PAGE

NOTE: If you do not get a confirmation page after pressing the Submit button, please let us know. We apologize for your inconvenience.

 

(If you are unable to send this application for technical reasons, click here for a fillable PDF version of the application which can be faxed to (434) 296-5800)


The information provided on this application will be released to the public upon request.

This information will be automatically sent to: 

Clerk, Board of County Supervisors 
Albemarle County
401 McIntire Road
Charlottesville, VA 22902-4596
FAX: (434) 296-5800

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