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Boards and Commissions Application Form

Application Status       

New Application 
Update to Previous Application

Prefix Mr.    Mrs.    Miss
Name
Home Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Name/Address
Work Phone
Home Phone
FAX
E-mail

Profession/Vocation

Agency on Aging, Peninsula Disability Services Board, Peninsula Regional Issues Committee
Alcohol Safety Action Program, Virginia Peninsula Employee Grievance Panel Senior Center Board
Arts Commission, York County Equalization, Board of Social Services Board, York-Poquoson
Beautification Committee Historical Committee Stormwater Advisory Committee, Citizens
Bicycle Committee, Regional Historic Yorktown Design Committee Thomas Nelson Community College Board
Building Code Appeals, Board of Industrial Development Authority Transportation Safety Commission
Colonial Group Home Commission Library Board Wetlands Board
Colonial Services Board Parks and Recreation Advisory Zoning/Subdivision Appeals , Board of
Community Correction Justice Board Planning Commission  

I would like to be considered for the following board(s)/commission(s): (Choose a maximum of three from the list above - in order of preference)

1.

2.

3.

Other Interests:

Education:

Job Experience:

Civic or Service Organization Experience:

Are you a graduate of the York County Citizen's Institute?

Yes

No

Are you currently a member of a York County board or commission?

Yes No

If Yes, please name:

Have you previously served as a member of a York County board or commission?

Yes No

If yes, please name:

Are you a registered voter?

Yes No

Voter District Number

Thank you for your application and your willingness to serve the citizens of York County.


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