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HomeMy WebLinkAboutAgenda - 01-31-2012 - 4ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: January 31, 2012 1 Action Agenda Item No. ~}- _SUBJECT: Orange County Boards and Commissions: Discussion of Applications DEPARTMENT: Board of Commissioners PUBLIC HEARING: (Y/N) No ATTACHMENT(S): Under Separate Cover Samples of Boards/Commissions Applications From Other Governmental Jurisdictions INFORMATION CONTACT: Clerk's Office, 245-2130 PURPOSE: To consider and discuss the current application/process for boards and commissions and provide direction for staff. BACKGROUND: As part of the Board's review of its boards and commissions' policies and procedures in 2011, the Board indicated interest in reviewing its current boards and commissions' application and/or process in order to better serve the residents of Orange County. FINANCIAL IMPACT: None. RECOMMENDATION(S): The Manager recommends for the Board to consider and discuss the current application/process for boards and commissions and provide direction for staff. 2 LISTING OF SAMPLE VOLUNTEER BOARDS/COMMISSIONS APPLICATIONS FROM OTHER GOVERNMENTAL ENTITIES (including Orange County) 1. Orange County 2. Town of Chapel Hill 3. Town of Carrboro 4. City of Durham 5. Durham County 6. Wake County 7. Guilford County 8. City of Greensboro 9. Mecklenburg County 10 . New Hanover County 11 . Brunswick County 12 . Buncombe County 3 Content of this application is a matter of public record N.C. Public Records Law requires that any information you provide on this application for volunteer service be available for public inspection. VOLUNTEER APPLICATION ORANGE COUNTY ADVISORY BOARDS AND COMMISSIONS If you are an Orange County resident, at least 18 years old, and willing to volunteer your time and expertise to your community, please complete this application and return to: Orange County Commissioners' Office P.O. Box 8181 Hillsborough, NC 27278 Phone (919) 245-2125 Fax: (919) 644-0246 Email: jjones@co.orange.nc.us NAME: HOME ADDRESS: CITY: PHONE: (Day) (Evening/late) (Fax) EMAIL: PLACE OF EMPLOYMENT: JOB TITLE: YEAR BECAME ORANGE COUNTY RESIDENT: IN ORDER TO ASSURE COUNTYWIDE REPRESENTATION PLEASE INDICATE YOUR TOWNSHIP OF RESIDENCE: ^Bingham ^Cheeks ^Hillsborough ^Eno ^Chapel Hill ^Little River ^Cedar Grove IN ADDITION, PLEASE INDICATE IF YOU LIVE IN ONE OF THE FOLLOWING AREAS: ^Joint Planning Area ^Extraterritorial Area ^Transition Area WE ASK YOUR HELP IN ASSURING DIVERSITY OF MEMBERSHIP BY AGE, GENDER AND RACE, BY ANSWERING THE FOLLOWING QUESTIONS: ^Male ^Female ETHNIC BACKGROUND: ^African American ^Caucasian ^Hispanic ^Native American ^Other DATE OF BIRTH: PLEASE LIST (IN ORDER OF PREFERENCE) THE BOARDS/COMMISSIONS ON WHICH YOU WOULD BE WILLING TO SERVE. WORK EXPERIENCE: 2. 3. Zip Code: VOLUNTEER EXPERIENC 4 EDUCATION: OTHER COMMENTS: How did you become aware of Orange County volunteer opportunities? (Please check all that apply): ^Newspaper ^County Web Page ^Current Orange County Volunteer ^Radio ^T.V. ^Other ETHICS GUIDELINES FOR COUNTY ADVISORY BOARDS AND COMMISSIONS I agree by my signature below that, if appointed, I pledge to comply with the following ethics guidelines for advisory boards and commissions as adopted by the Orange County Board of Commissioners. • Members of advisory boards and commissions shall not discuss, advocate, or vote on any matter in which they have a conflict or potential conflict of interest or an interest which reasonably might appear to be in conflict with the concept of fairness in dealing with public business. A conflict of interest or a potential conflict occurs if a member has a separate, private, or monetary interest, either direct or indirect, in any issue or transaction under consideration. Any member who violates this provision may be subject to removal from the board or commission. If an advisory board or commission member believes he/she has a conflict or potential conflict of interest on a particular issue, then that member should state this belief to the other members of his/her respective advisory board or commission during the board or commission's public meeting. The member should state the nature of the conflict, detailing that he/she has a separate, private, or monetary interest, either direct or indirect, in the issue or transaction under consideration. The member should then excuse himself/herself from considering and voting on the matter. In cases where an advisory board or commission member declares a conflict or potential conflict of interest, the member shall excuse himself/herself from the board table/voting area until all discussion, consideration, and voting is completed on the matter in question. • Any advisory board or commission member having questions or needing assistance regarding the interpretation of these ethics guidelines or other conflict of interest matters should contact the administrative staff for the respective board or commission. Staff will assist the member with questions and interpretations and may provide a recommendation on whether or not the advisory board or commission member should excuse himself/herself from voting. The member may request that the staff respond in writing. Staff may contact the County Manager for any additional assistance. • N.C. Public Records Law requires that any information that you provide on this application for volunteer service be available for public inspection. If appointed, I agree to attend athree-hour orientation which will give an overview of how Orange County Government operates and its relationship to other governmental units. Signature Date VOLDISK3:APPLCTN; C:~...VOLAPP3.DOC 5 APPLICATION FOR MEMBERSHIP ON TOWN OF CHAPEL HILL ADVISORYBOARD, COMMISSION, COMMITTEE OR TASK FORCE This application requests some general information based on your interest in applying for a position on a Chapel Hill Town Advisory Board, Commission, Committee or Task Force. Please type or use dark ink. Applicant's Legal Name: Home Address: Home Phone: FAX Number: Email Address: Date of Application: / / In order to consider this application and provide some balance to the various boards, this personal information is required: Male: ^ Female: ^ Ethnicity: (African American, Asian, Caucasian, Hispanic, Native American) Date of Birth: / / Occupation: Residency within the Town limits is required for membership on most Council advisory boards and commissions. Memberships of committees and task forces may be composed of up to forty percent of non- Town residents. Do you reside within the Town Limits of Chapel Hill: Yes ^' No ^! Length of residence in Chapel Hill: Years Months How did you find out about this Board? (please circle or underline one) Newspaper, Email, Friend, TV, Internet, Current Member, Brochure, Bus Poster, Radio, Magazine, Speaker at Event, Other The Council encourages you to visit a meeting of the group that you are interested in serving on. Please indicate your preferences by number (first choice being "1") and choose no more than three, along with category, if applicable. COUNCIL ADVISORY BOARDS AND COMMISSIONS Bicycle and Pedestrian Advisory Board Library Board of Trustees Board of Adjustment Cemeteries Advisory Board Chapel Hill Downtown Partnership Chapel Hill Public Arts Commission Community Design Commission Community Policing Advisory Committee Greenways Commission Historic District Commission Human Services Advisory Board Personnel Appeals Committee Planning Board Public Housing Program Advisory Board Stormwater Management UtiliTy Advisory Board Sustainability Committee Transportation Board OTHER COUNCIL COMMITTEES AND TASK FORCES (Please Specify): Category(s) if applicable: Street Address, City, Zip Code Business/Other Phone: Orange Water & Sewer Authority (OWASA) Parks & Recreation Commission - over - - \\chfs\Clerk\Boards_Commissions_Committees_etc\Forms\Applications\DO NOT SEND Application Form 3-2011 - Copy.doc Comm & Public Affairs/3-2010 6 ETHICS GUIDELINES FOR TOWN ADVISORY BOARDS AND COMMISSIONS (Please check if you agree.) Yes, if appointed, I pledge to comply with the following ethics guidelines for advisory boards and commissions as adopted by the Chapel Hill Town Council. (Other Council committees and OWASA are excluded.) Members of advisory boards and commissions shall not discuss, advocate, or vote on any matter in which they have a conflict of interest or an interest which reasonably might appear to be in conflict with the concept of fairness in dealing with public business. A conflict of interest or a potential conflict occurs if a member has a separate, private, or monetary interest, either direct or indirect, in any issue or transaction under consideration. Any member who violates this provision may be subject to removal from the board or commission. If the advisory board or commission member believes he/she has a conflict of interest then that member should ask the advisory board or commission to be recused from voting. The advisory board or commission should then vote on the question on whether or not to excuse the member making the request. In cases where the individual member or the advisory board or commission establishes a conflict of interest, then the advisory board or commission member shall remove themselves from the voting area. Any advisory .board or commission member may seek the counsel of the Town Attorney on questions regarding the interpretation of these ethics guidelines or other conflict of interest matters. The interpretation may include a recommendation on whether or not the advisory board or commission member should excuse himself/herself from voting. The advisory board or commission member may request the Town Attorney respond in writing. Please provide a brief statement outlining why you wish to serve on the Advisory Board(s), Commission(s), Committee(s) or Task Force(s) to which you are applying. Applicant's Signature Required Date Applications will be purged after two spring appointment cycles (approximately two years). Please reapply at that time if you are still interested in serving on an Advisory Board Commission, Committee or Task Force and have not yet been appointed. Please return form to: Communications and Public Affairs Department, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514 Email clerk(cr~,townofchapelhill.org or FAX 919-967-8406 7 Town ETJ Trans.Area TOWN OF CARRBORO .~..~ Application for Membership on Advisory-Board ~ ~~ ~-- NAME: ADDRESS: DATE: IS THIS ADDRESS LOCATED WITHIN THE CORPORATE LIMITS OF THE TOWN OF CARRBORO? TELEPHONE:[HOME] _ [BUSINESS] _ DATE OF BIRTH: _ E-MAIL ADDRESS: RACE: SEX: LENGTH OF RESIDENCE IN ORANGE COUNTY: OCCUPATION: ARE YOU A REGISTERED ORANGE COUNTY VOTER? TOWN OF CARRBORO: COMMUNITY ACTIVITIES/ORGANIZATIONAL MEMBERSHIPS: I wish to be considered for appointment to the following advisory board(s): ^ Board of Adjustment ^ Northern Transition Area Advisory Com. ^ Appearance Commission/NPDC ^ OWASA Board of Directors ^ Arts Committee ^ Orange County Economic Dev. Com. ^ Economic Sustainability Commission ^ Orange County Human Relations Com. ^ Environmental Advisory Board ^ Personnel Advisory Committee ^ Greenways Commission ^ Planning Board ^ Human Services Commission ^ Recreation & Parks Commission ^ Transportation Advisory Board ^ Other If you apply for membership on more than one advisory board, please indicate your preference by number, with "1" being your first choice (please limit your selection to two (2) boards). Please note that membership is limited to one advisory board at a time. You shall not be considered for appointment to another board unless you resign before filing an application or you are in the last six months of your current term. EXPERIENCE TO AID YOU IN WORKING ON THESE ADVISORY BOARDS: REASON(S~ YOU WISH TO BE APPOINTED: HAVE YOU EVER SERVED ON ANY TOWN OF CARRBORO ADVISORY BOARD? IF "YES", WHICH ONE(S~ RETURN THIS FORM TO: TOWN CLERK, 301 WEST MAIN STREET, CARRBORO, N. C. 27510 www.townofcarrboro.or~ (Please note that this document and the information contained on it is a public record and must be provided by the town to anyone requesting a copy of i~) 9 ~ ~ ~'~ CITY OF DURHAM, NORTH CAROLINA - Board, Commissions, and Committees Application Office of the City Clerk 101 City Hall Plaza • Durham, NC 27701 Phone Number: (919) 560-4166 ~ ~ ~ ~ Fax Number: (919) 560-4835 ~- ~ ~ = Website: www.durhamnc.gov - Please complete this application in its entirety - Only applications with signature will be accepted - Complete one application per Board/Comxnission/Committee - Return application to above address via USPS or Fax - Hours of Operation: 8:00 a.m. - 4:30 p.m. Monday through Friday - Property Tax Listing must be current. City and County Taxes must not reflect any delinquencies - Application will be released to the public upon request Application is active at the time of vacancy only ETHNIC BACKGROUND ARE YOU AT LEAST 18 YEARS OF AGE? ^ YES ^ NO SEX: ^ MALE ^ FEMALE ^ Audit Services Oversight Committee ^ Durham Cultural Advisory Board ^ Homeless Services Advisory Committee ^ Capital Program Advisory Committee ^ Durham Housing Authority ^ Housing Appeals Boazd ^ Citizens Advisory Committee ^ Durham Open Space & Trails Commission ^ Human Relations Commission ^ Convention & Visitors Bureau Board of Directors ^ DPAC Oversight Committee ^ Lyon Park Advisory Board ^ Design District Review Team ^ Durham Plannin Commission g ^ Passenger Vehicle For Hire Commission ^ Durhazn Bicycle and Pedestrian Advisory Commission ^ Environmental Affairs Board ^Ra1eigh-Durham Airport Authority ^ Durham Board of Adjustment ^ EBOP Advisory Committee ^ Recreation Advisory Commission ^ Durham City-County Appearance Commission ^ Firefighter's Relief Fund Board of Trustees ^ Triangle Transit Authority ^ Durham Convention Center Authority ^ Historic Preservation Commission ^ Workforce Development Boazd Do you live within the Corporate City Limits? ^ YES ^ NO Name of any City of Durham Board/Commission/Committee that you are serving on at the present time Date Term Expires NAME HOME Business SPOUSE NAME Street City State Zip Code Home Phone Place of Business Email Address Occupation Street City State Zip Code Business Phone City of Durham Board, Commission, Committee Application EDUCATION Based on your qualifications and experiences, briefly describe why your service on the above BOARD/COMMISSION/COMMITTEE would be beneficial to the City of Durham Other information you consider pertinent: (i.e., Civic memberships, related experience, etc.) 10 Page 2 Date of Application Applicant Signature (Office Use Only) DATE CLERK'S OFFICE RECEIVED APPLICATION CLERK'S INITIALS ~~o ~~• ~~ ~,~. '-~r~,.. ,oy~~ Date Received Application for: Authorities, Boards, Commissions, and Committees Note: All information on this document will be released to the public on request. PLEASE P R I N T clearly: Name: Ethnic Background: Sex: (M) (F)_ Home Phone Number: Age (over 18): Yes No Home Fax Number: Email Address: (Please provide this contact inforrrurt~) Home Address: (street) (city) (state) (zip) Name of Authority/Board/Commission/Committee: Specific category applying for: (e.g. Nurse, Attorney, At-Large, etc.) Qualification for specific category: Occupation: Place of Business: Business Address: (street) Business Phone Number: Do you live within Durham County? Yes Do you live within the corporate city limits? Yes Education: (city) Business Fax Number: No Township: _ No (state) (zip) 11 12 Name of any Durham County or City of Durham Board/Commission/Committee on which you presently serve: If reapplying for a position you presently hold, how many consecutive terms have you served? Based on your qualifications and experiences, briefly describe why your services on this Authority/ Board/Commission/Committee would be beneficial to the County of Durham: Are your taxes current (e.g. animal, property, vehicle)? Yes No Are your City and County property and motor vehicle taxes paid in full on a current basis? Yes No Other information you consider pertinent: (i.e., civic memberships, related work experience, etc.): (If necessary, you. may add additional pages.) (Check if additional pages are added: ) Note: All information on this document will be released to the public on request. Date: Applicant's Signature: Return application to: Clerk to the Board of County Commissioners 2nd Floor -- 8:30 a.m.-5:00 p.m. Mailing Address: Durham County Government Administrative Complex 200 East Main Street Durham, NC 27701 Fax Number: (919) 560-0013 userdata\board-ap.doc Wake County -Authorities, Boards, Commissions and Committees, Wake County Volunt... Page 1 of 3 13 Volunteer Application Wake County Advisory Boards and Commissions If you are a Wake County resident, at least 18 years old, and willing to volunteer your time and expertise to your community, please complete and submit this form. (Required fields are indicated by an asterisk *.) First Name: Last Name:* Street Address: (Use residential street address, not a P.O. box.) City: State: Zip:* _. _ NC Home Phone:* Work Phone: FAX: (Required phone number format is XXX-XXX-~CXX) In order to assure countywide representation, please indicate your place of residence: If you live in an Extraterritorial Jurisdiction Area, check here: ^ Yes We ask your help in assuring diversity of membership by age, gender, and race by answering the following questions: Sex: Ethnic Background: ___ Date of Birth: (mm/dd/yyyy) _ _ __.. Please select (in order of preference) the boards or commissions on which you are willing to serve (You must select at least one board.): 1. 2. 3. http://Inweb02.co.wake.nc.us/boards/boards.nsf/WebApp 12/9/2011 Wake County -Authorities, Boards, Commissions and Committees, Wake County Volunt... Page 2 of 3 14 __ ____ __ _ -_ - _ _ __ ._ __ 4. __ 5. 6. __ ................... WORK EXPERIENCE: !_ VOLUNTEER EXPERIENCE: ~' How did you become aware of Wake County volunteer opportunities? If Other, how? If you have a resume or other document you would like to attach to your application, you may upload it below: Browse... ETHICS GUIDELINES FOR COUNTY ADVISORY BOARDS AND COMMISSIONS By submitting this electronic application, I pledge that, if appointed I agree by my signature below that, if appointed, I pledge to comply with the following ethics guidelines for advisory boards and commissions as adopted by the Wake County Board of Commissioners. http://lnweb02.co.wake.nc.us/boards/boards.nsf/WebApp 12/9/2011 Wake County -Authorities, Boards, Commissions and Committees, Wake County Volunt... Page 3 of 3 15 I. Declaration of Policy The proper operation of democratic government requires that public officials and employees be independent, impartial and responsible to the people; that governmental decisions and policy be made in proper channels of the governmental structure; that public office not be used for personal gain; and that the public have confidence in the integrity of its government. In recognition of these goals, a Code of Ethics for County officials is hereby adopted. The purpose of this policy is to establish guidelines for ethical standards of conduct for all such officials by setting forth those acts or actions that are compatible with the best interests of the County. II. Applicability of Ethics Policy The provisions of this policy shall apply to all elected and appointed County officials, members of County boards and commissions appointed by the County commissioners, and other County employees. II. Financial and Personal Disclosure Any County official or employee who must officially consider any public matter involving his financial or personal interests, or those of his immediate family, shall first publicly disclose the nature and extent of such interest and shall abstain from acting thereon unless provisions of state law require otherwise. III. Gifts and Favors No official or employee shall knowingly accept any gift, whether in the form of money, thing, favor, loan or promise, when it could reasonably be inferred that the gift was intended to influence or reward an official action on his part. Gifts, meals, other favors of an incidental nature and of minor value, or legitimate political contributions shall not be included in this policy. IV. Appointment, Employment, or Contract Award of Relatives or Business Partners Public officials of the appointing authority must disclose on the public record any person of their immediate family related by blood or marriage, or business interest who is being considered for appointment, employment or contract award by that authority. Immediate family related by blood and marriage are to include: spouse, child, parents, brothers, sisters, grandparents, grandchildren, step-, and in-law relationships for preceding categories. Submit Form Clear Form http://inweb02.co.wake.nc.us/boards/boards.nsf/WebApp 12/9/2011 Volunteer Application Form Page 1 of 2 17 VOLUNTEER APPLICATION GUILFORD COUNTY ADVISORY BOARDS AND COMMISSIONS If you are a Guilford County resident, at least 18 years old, and willing to volunteer your time and expertise to your community, please complete and submit this form. Date: 12/9/2011 Please Enter Your Name: Title: First: Last: Suffix: ___ _ (Mr.,Mrs.,etc.) _ (Sr.,Jr.,etc.) Preferred Name: (if different from First Name) Home Address: City: State: Zip: NC Fax Phone: Home Work ext. ( ) __. ( ) ( ) - - Email Place of Employment: In order to help us comply with State reporting requirements, please complete the following questions: Sex: (unspecified) Race: (unspecified) __ Date of Birth: (mm/dd/yyyy) Please list (in order of preference) the Boards/Commissions on which you would be willing to serve. 1. - 2. - 3. - http://www.co.guilford.nc.us/boardapp/boards.asp 12/9/2011 Volunteer Application Form Page 2 of 2 18 Please list any work, volunteer, and/or educational experience you would like us to consider in the review of your application. Feel free to submit a resume via e-mail or postal mail (Crystal Maurer, County Commissioners' Office, P. O. Box 3427, Greensboro, N.C. 27402). Resume: Work Experience: Volunteer Experience: Education: Other Comments: Submit Form Clear Form TOP OF PAGE Copyright ©2001-2005 Guilford County. All Rights Reserved. htip://www.co.guilford.nc.us/boardapp/boards.asp 12/9/2011 19 CITY OF GREENSBORO INTEREST FORM FOR SERVICE ON BOARDS AND COMMISSIONS 1. NAME 2. ADDRESS (HOME) (WORK (E-mail address) 3. TELEPHONE NUMBER: WORK 4. GENDER: FEMALE 5. RACE: CAUCASIAN HISPANIC MALE HOME AFRICAN-AMERICAN AMERICAN INDIAN OTHER 6. PROFESSION (TITLE): 7. GREENSBORO COUNCIL, DISTRICT WHEREIN NOMINEE RESIDES: (MUST RESIDE IN THE CITY OF GREENSBORO) 8. SPECIFIC CITY BOARD/COMMISSION OF INTEREST 9. CITY ACADEMY GRADUATE 10. LEASE ATTACH RESUM SIGNED: Applications will be pursed after two years. Please consider reapplying at that time if you remain interested in serving on a Board and have not yet been appointed. Send to City Clerk, P.O. Box 3136, Greensboro, NC 27402-3136 - 336- 373-2397 -fax 336-574-4003 E-mail: Betsey.Richardson(cr~reensboro-nc.eov Revised November 2010 Board Application Page 1 of 2 21 Mecklenburo County > BOCC > Advisors Boards > Board Application Mecklenburg County Advisory Board Application The Mecklenburg County Board of Commissioners appreciates the interest of all citizens willing to serve their Community through participation on County advisory boards. For a hard copy of the ' application form, call the Clerk's office, or send an E-mail. You can also submit the application online thanks to Mecklenburg County e-Government: (one board per application) Name of Advisory Board: Name: _ ', (Please do not use P.O. Box numbers.) Home address: _ _ __ _ __ City ' Zip code: Home Phone: Work Phone: E-Mail: Occupation: ', Place of employment: _ _ _ _ Race: Sex: _' Female ._.' Male Age: j Hours per month available ' for position: -- --- County advisory board currently serving on: ._ ......................................_.... Expiration date: Education: Business and civic experience: _ __ _. _ . Areas of expertise and interests/skills: Below are boards requiring representation of certain professions or sectors of the community. Please check where applicable. Thank you for your interest in serving your community. Board of Equalization and Review !J! Attorney ' ~~ CPA _Commercial Real Estate Representative ' ~_.~ Residential Real Estate Representative Adult Care/Nursing Home Committies Your response will determine which you are eligible for. If none apply, you're eligible for both. : ...i Do you or an immediate family member have a financial interest in a home served by the committee? Are you an employee or a board member of a home served by the committee? IIS an immediate family member a resident in an Adult Care or Nursing Home? Building Development Commission http://charmeck.org/mecklenburg/countyB OCC/AdvisoryBoards/PagesBoardApplication.... 12/9/2011 Board Application Page 2 of 2 22 u Master Electrical Contractors Association of North Carolina, Inc. Mecklenburg General Contractors Association ',_~ Development Industry (nominated by The Charlotte Chamber of Commerce) Home Builders Association of Charlotte Charlotte Chapter of American Society of Landscape Architects ~ Charlotte Heating and Air Conditioning Contractors Association Charlotte Plumbing, Heating, Cooling Contractors Association Professional Engineers of North Carolina-South Piedmont Chapter Multi-family residential industry represent the Charlotte Apartment Association National Association of the Remodeling Industry of Charlotte General Public Representative ,~ American Institute of Architects-Charlotte Please check only one of the qualifications/categories below. Criminal Justice Citizens' Advisory Committee County Commission District: Choose one ', ^The Mecklenburg County Bar (Recommended by the Criminal Justice Section of the Mecklenburg County Bar) '~~~.] Law Enforcement Representative '. -i Charlotte-Mecklenburg School System Representative Substance Abuse Professional (e.g., A licensed social worker or psychologist) Member of the Faith Community ~A person who has been rehabilitated, but gone through the Mecklenburg County criminal justice system. (The individual should be proposed for consideration by The Center for Community Transitions) Signature of applicant: Date: Submit http://charmeck. org/mecklenburg/countyBOCC/AdvisoryBoards/PagesBoardApplication.... 12/9/2011 NEW HANOVER COUNTY BOARD OF COMMISSIONERS 230 Government Center Drive, Suite 175 Wilmington, NC 28403 COMMITTEE APPLICATION Telephone (910) 798-7149 FAX (910) 798-7145 Board/Committee: Name: E-Mail: 23 ~~ ~~' ~=1 Home Address: reet y ~p o e Mailing Address if different: Home Phone: (City) (Zip Code) Fax: Cell: Business: Years living in New Hanover County: Male: Female: Race: Age: (Information for the purpose ofassuring across-section of the community) Do you have a family member employed by New Hanover County? ff yes, name Employer. A person currently employed by the agency or department for which this application is made, must resign his/her position with New Hanover County upon appointment in accordance with Artide Vl, Sec. 4 of the New Hanover County Personnel Policy. Furthemrore, applicant should have no immediate family member employed by such agency or department. Occupation: Professional Activities: Volunteer Activities; Why do you wish to serve on this board/committee? Conflict of Interest: ff a board member believes he/she has a conflict or potential conflict of interest on a particularissue, that member should state this belief to the other members of his/her respective board during a public meeting. The member should state the nature of the conflict detailing that he/she has a separate, private, or monetary interest either direct or indirect, in the issue under consideration. The member should then excuse himself/herself from voting on the matter. What areas of concern would you like to see addressed by this committee? Qualifications for serving: Other municipal or county boards/committees on which you are serving: List three local personal references and phone numbers: 1. 2. 3. Date: Applications are kept on file for 18 months Please use reverse side for additional comments Signature I understand that any board or committee appointee maybe removed without cause by a majority of County Commissioners. 25 RETURN THIS APPLICATION TO: Deborah Gore, Clerk to the Board Post,lDffice Box 249 Bolivia, North Carolina 29422 Email Your Application To: dgo re(rr~. b ru n sco. n et Phone Number: 910-253-2017 Fax Number: 910-253-2004 BRUNSWICK COUNTY APPLICATION FOR APPOINTMENT TO BOARDS AND COMMITTEES The undersigned is interested in community service and provides this information for use by the Brunswick County Board of Commissioners in considering his/her qualifications for appointment to boards or committees. PLEASE PRINT I am interested in serving on: Full Name: List complete address: (Please include street name, town, post office box number, all that is applicable) Home Phone: Area Code: Email Address: Mobile Number: Permanent Resident of Brunswick County [Yes] [No] How many years? Registered to vote in Brunswick County [Yes] [No] Present Job/Employer Address: Fax Number Past Employment: Educational Background/Experience/Training that would qualify for appointment: Are you currently serving on any other Boards in Brunswick County: [Yes] [No] 26 Current Civic/Community Participation: Do you anticipate any conflicts of interest if appointed? [No] [Yes] Explain: Signature of Applicant Date 27 ~` BUiNCt)MBE ~,M,`"`r~ ~~ t„1 NTY NORFtt CARQLIkVA M1~~~I~r1~ -coutxn~aeus-.~- Yt~tn 1'atrrrr itfreu ('nmmu+dtp Buncombe County Board of Commissioners David Gantt, Chairman K. Ray Bailey, Commissioner Carol Peterson, Commissioner Bill Stanley, Commissioner Holly Jones Commissioner Application for Appointment to: (Board or Commission name) Name: Date: Home Address Business Name: Address ~ Phone: E-mail: List any County Board, Committee or Commission on which you currently serve: How did you hear about this Board vacancy? For the purpose of diversity and balance, please complete the following: Race Male Female Buncombe County residency is required for appointment to any board or commission. I am a resident from the North_ South_ East_ West City of Asheville (check one) I have been a resident of Buncombe County for years. Return application to: Clerk to the Board of Commissioners 205 College Street Suite 300 Asheville, NC 28801 kathy. hughes@buncombecounty. org Phone: 828-250-4105 FAX: 828-250-6077 Signature of Applicant (this application will be kept on file for one year) Buncombe County does not discriminate on the basis of race, color, religion, sex, age, national origin, handicap or disability in admission or access to or treatment or employment in its services, programs and activities in compliance with applicable federal and state laws. Information given on this application is public record. buncambecaunty.org Volunteer Application 2 8 Watauga County Boards And Commissions If you are a Watauga County resident, at least 18 years old, and willing to volunteer your Gme and expertise to your community, please complete the application below and dick on Print Form. Please sign and mail or fax to: Watauga County Commissioners' Office 814 West King Street, Suite 205 Boone, NC 28607 Phone: (828) 265-8000 Fax: (828) 264-3230 Name: Home Address: City: Zip: Telephone: (H) ~ (Fax) Email: Place of Employment: Job Title: In Order To Assure County wide Representation Please Indicate Your Townshi p Of Residence: {` Bald Mountain (~ Stony Fork (` Watauga (~` New River {`: Brushy Fork Cove Creek ('`, Beaver Dam (+' Meat Camp (~ Shawneehaw {~` Blue Ridge (" Blowing Rodc {` Laurel Creek (~` Elk (`.:North Fork (~ Boone In addition, Please Indicate If You Live In One Of The Following Areas: Foscoe-Grandfather Community ("':, Valle Crucis Historic Distrid (` Howards Creek Watershed {~ Winklers Creek Watershed (`,South Fork New River Watershed ~"'; Extraterritorial Area We Ask Your Help In Assuring Diversity Of Membership By Age, Gender, And Race, By Answering The Following Questions Gender Ethnic Background {y Male (`; African American (~ Hispanic {". Female {~ Caucasian r-Other (": Native American Please List (In Order Of Preference) The Boards/Commissions On Which You Would Be Willing To Serve. 1. 2. 3. Volunteer Application Watauga County Boards And Commissions (Continued) Please list any work, volunteer, and/or other experience you would like to have considered in the review of your application. Work Experience: Volunteer Experience: Other Experience: Other Comments: Signature: Date: 1 /13/12 29