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2. First Name
3. Last Name
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Email Address
14. Comments
16. Ethnic Background

    1. African American
    2. Caucasian
    3. Hispanic
    4. Other
17. Sex

    1. Male
    2. Female
18. Age

    1. Under 18
    2. 18 to 30
    3. 31 to 50
    4. 51 to 65
    5. Over 65
20. Are you a full-time resident of Northampton County?

    1. Yes
    2. No
21. Years of Residency
22. Name of Township
24. Do you live within any corporate or town limits?

    1. Yes
    2. No
25. Name of Town
27. Employer Name
29. Employer Address
31. List any qualifications and why you are interested in serving on the Authority/Board/Commission/Committee
33. Check any Northampton County Authority/Board/Commission/Committee on which you: Presently Serve/Interested

    1. ABC Board
    2. CADA Board
    3. Choanoke Public Transportation
    4. Halifax-Northampton Regional Airport
    5. Cooperative Ext. Advisory Leadership Members for 2016
    6. Hertford-Northampton Smart Start Partnership for Children
    7. Home and Community Block Grant Advisory Council
    8. Lake Gaston Weed Control Council
    9. Northampton County Animal Cruelty Investigator
    10. Northampton County Board of Adjustment
    11. Northampton County Planning Board
    12. Northampton County Board of Health
    13. Northampton County Cultural Arts
    14. Northampton County Economic Development Commission
    15. Northampton County Library Board
    16. Northampton County Tourism Development Authority
    17. Northampton County Recreation Department
    18. Northampton County Recreation & Cultural Arts Center, Inc.
    19. Tri-County Airport Authority
    20. Roanoke-Chowan Regional Housing Authority
    21. Upper Coastal Plain Council of Government Joint Nursing & Adult Care Community Advisory Committee
    22. Upper Coastal Plain Council of Government-Northampton County Executive Committee
    23. Upper Coastal Plain Council of Governments-Northampton County Full Board Members
    24. Turning Point Workforce Development Board
    25. Trillium Health Resources
35. Date
    Date
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

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