STATE OF NORTH CAROLINA COUNTY OF NORTHAMPTON
 Application for: Authorities, Board, Commissions and Committees

Please Note: All information on this document will be released to the public on request.

Name:

Address:

Address Line 2:

City or Town:

State or Province:

Zip or Postal Code:

Phone:

Fax:

Email:

Comments:


Ethnic Background: African American   Caucasian   Hispanic   Other

Sex:  Male   Female   Age: Under 18   18-30   31-50   51-65   Over 65

Are you a full-time resident of Northampton County:  Yes    No   Years  Township:

Do you live within any corporate or town limits:  Yes  No  Town:

Employer Name and Address:

List any qualifications and why you are interested in serving on the Authority/Board/Commission/Committee:

Check any Northampton County Authority/Board/Commission/Committee on which you:
Presently Serve/Interested:
                                       ABC BOARD     
                                       CADA BOARD     
                                       CHOANOKE PUBLIC TRANSPORTATION     
                                       HALIFAX-NORTHAMPTON REGIONAL AIRPORT     
                                       COOPERATIVE EXT. ADVISORY LEADERSHIP MEMBERS FOR 2016     
                                       HERTFORD-NORTHAMPTON SMART START PARTERSHIP FOR CHILDREN    
                                       HOME AND COMMUNITY BLOCK GRANT ADVISORY COUNCIL     
                                       LAKE GASTON WEED CONTROL COUNCIL     
                                       NORTHAMPTON COUNTY ANIMAL CRUELTY INVESTIGATOR     
                                       NORTHAMPTON COUNTY BOARD OF ADJUSTMENT     
                                       NORTHAMPTON COUNTY PLANNING BOARD     
                                       NORTHAMPTON COUNTY BOARD OF HEALTH     
                                       NORTHAMPTON COUNTY CULTURAL ARTS      
                                       NORTHAMPTON COUNTY ECONOMIC DEVELOPMENT COMMISSION     
                                       NORTHAMPTON COUNTY LIBRARY BOARD     
                                       NORTHAMPTON COUNTY TOURISM DEVELOPMENT AUTHORITY     
                                       NORTHAMPTON COUNTY RECREATION DEPARTMENT     
                                       NORTHAMPTON COUNTY RECREATION & CULTURAL ARTS CENTER, INC    
                                       TRI-COUNTY AIRPORT AUTHORITY     
                                       ROANOKE-CHOWAN REGIONAL HOUSING AUTHORITY     
                                       UPPER COASTAL PLAIN COUNCIL OF GOVERNMENT JOINT NURSING &                                                 ADULT CARE COMMUNITY ADVISORY COMMITTEE 
                                       UPPER COASTAL PLAIN COUNCIL OF GOVERNMENT-NORTHAMTPON                                                 COUNTY EXECUTIVE COMMITTEE 
                                       UPPER COASTAL PLAIN COUNCIL OF GOVERNMENTS-NORTHAMPTON                                                 COUNTY FULL BOARD MEMBERS 
                                       TURNING POINT WORKFORCE DEVELOPMENT BOARD     
                                       TRILLIUM HEALTH RESOURCES     

 Date: