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2. Application for Boards, Commissions, and Committees
4. Date*
   Date
6. First Name*
7. Last Name*
9. Physical Address*
11. City*
12. State*
13. Zip*
15. Mailing Address (If Different Than Above)
17. City
18. State
19. Zip
21. Phone Number*
22. Fax Number
24. Email*
25. Election District
    -- Select One --District 1District 2District 3District 4District 5
29. Present Employer
31. Employer Address
33. City
34. State
35. Zip
37. Employer Phone Number
38. Employer Fax Number
42. Which address is preferred for mailings?*

    1. Home

    1. Business
46. Additional Information

    Please provide additional information that may be helpful for your appointment.

48. Occupation
49. Former Occupation (If Retired)
51. Education

    Please list school(s) and study area(s).

53. High School
55. College / Technical School
57. Graduate School
59. Other
61. Past Board, Commission or Committee Assignments
63. Professional, Civic, or Other Activities
67. Interest in Boards, Commissions, and Committees

    Please select any boards, commissions, or committees you are interested in and willing to serve on.

69. Appointed by the Board of Supervisors*

    1. Airport Commission
    2. Board of Building Code Appeals
    3. Board of Zoning Appeals
    4. Economic Develop. Authority
    5. Germanna Comm. College Bd.

    1. Health Center Commission
    2. Lake Anna Advisory Committee
    3. Library Board
    4. Litter Control Committee
    5. Parks and Rec. Foundation

    1. Piedmont Workforce Dev. Bd.
    2. Planning Commission
    3. Rappahannock EMS Council
    4. Rapp-Rap Comm. Services Bd.
    5. Skyline Community Action

    1. Social Services Board
    2. TJ Area Criminal Justice Board
    3. Tourism Advisory Committee
    4. Youth Commission
71. Order of Preference*
    Please list your selected boards, commissions, and committees in order of preference.
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field