Name:

* Title: (Title = Dr., Mr., Ms., etc.)

* First Name:

* Last Name:

Suffix: (Suffix = Jr., Sr., IV, etc.)

* Street Address: (no P.O. Boxes please)

* City:

* State:

* Zip Code:

* Daytime Phone:

Evening Phone:

FAX:

EMail Address:

Place of Employment:

Job Title:

What year did you become a resident of Orange County?

In order to assure countywide representation, please indicate your township of residence:.

- Bingham Cedar Grove Chapel Hill Cheeks Eno Hillsborough Little River

In addition, please indicate if you live in one of the following areas:

- JPA (Joint Planning Area) EA (Extraterritorial Area) TA (Transition Area) Does not apply

We ask your help in assuring diversity of membership by age, gender, and race by answering the following questions:

Sex: - Female Male

Ethnic Background: - African American Asian American Caucasian Hispanic Native American Other

Please list (in order of preference) the Boards/Commissions on which you would be willing to serve.

* 1. --- `Adult Care Home Community Advisory Committee Advisory Board on Aging Affordable Housing Advisory Board Agricultural Preservation Board Alcoholic Beverage Control Board Animal Services Advisory Board Arts Commission Board of Health Board of Social Services Carrboro Board of Adjustment Carrboro Northern Transition Area Advisory Committee Carrboro Planning Board Carrboro Recreation and Parks Commission Chapel Hill Board of Adjustment Chapel Hill Library Board of Trustees Chapel Hill Parks and Recreation Commission Chapel Hill Planning Board Chapel Hill/Orange County Visitors Bureau Climate Control Board Commission for the Environment Durham Technical Community College Board of Directors Economic Development Advisory Board Efland-Mebane SAP Implementation Focus Group Equalization and Review Board Hillsborough Board of Adjustment Hillsborough Planning Board Historic Preservation Commission Historic Rogers Road Task Force (CURRENTLY NOT ACCEPTING APPLICATIONS) Hollow Rock Park Planning Committee Homestead & H.S. Roads Safety Task Force Human Relations Commission Hyconeechee Regional Library (Currently not accepting applications) Interlocal Agreement Committee for the Hillsborough Area-Orange County Strategic Growth Plan Phase II IP (Intergovernmental Parks) Work Group Joint Orange Chatham Community Action Agency Jury Commission Mebane Board of Adjustment Mebane Planning Board Nursing Home Community Advisory Committee Orange County Board of Adjustment Orange County Emergency Services Work Group (CURRENTLY NOT ACCEPTING APPLICATIONS) Orange County Housing Authority Orange County Parks and Recreation Council Orange County Planning Board Orange Unified Transportation Board Orange Water & Sewer Authority Board of Directors Orange-Chatham Justice Leadership Council Orange-Person-Chatham Area Programs Board Personnel Hearing Board Piedmont Food & Agricultural Processing Center Steering Committee Solid Waste Advisory Board Ten (10) Year Plan to End Homelessness Executive Team Workforce Development Board - Regional Partnership

2. --- `Adult Care Home Community Advisory Committee Advisory Board on Aging Affordable Housing Advisory Board Agricultural Preservation Board Alcoholic Beverage Control Board Animal Services Advisory Board Arts Commission Board of Health Board of Social Services Carrboro Board of Adjustment Carrboro Northern Transition Area Advisory Committee Carrboro Planning Board Carrboro Recreation and Parks Commission Chapel Hill Board of Adjustment Chapel Hill Library Board of Trustees Chapel Hill Parks and Recreation Commission Chapel Hill Planning Board Chapel Hill/Orange County Visitors Bureau Climate Control Board Commission for the Environment Durham Technical Community College Board of Directors Economic Development Advisory Board Efland-Mebane SAP Implementation Focus Group Equalization and Review Board Hillsborough Board of Adjustment Hillsborough Planning Board Historic Preservation Commission Historic Rogers Road Task Force (CURRENTLY NOT ACCEPTING APPLICATIONS) Hollow Rock Park Planning Committee Homestead & H.S. Roads Safety Task Force Human Relations Commission Hyconeechee Regional Library (Currently not accepting applications) Interlocal Agreement Committee for the Hillsborough Area-Orange County Strategic Growth Plan Phase II IP (Intergovernmental Parks) Work Group Joint Orange Chatham Community Action Agency Jury Commission Mebane Board of Adjustment Mebane Planning Board Nursing Home Community Advisory Committee Orange County Board of Adjustment Orange County Emergency Services Work Group (CURRENTLY NOT ACCEPTING APPLICATIONS) Orange County Housing Authority Orange County Parks and Recreation Council Orange County Planning Board Orange Unified Transportation Board Orange Water & Sewer Authority Board of Directors Orange-Chatham Justice Leadership Council Orange-Person-Chatham Area Programs Board Personnel Hearing Board Piedmont Food & Agricultural Processing Center Steering Committee Solid Waste Advisory Board Ten (10) Year Plan to End Homelessness Executive Team Workforce Development Board - Regional Partnership

3. --- `Adult Care Home Community Advisory Committee Advisory Board on Aging Affordable Housing Advisory Board Agricultural Preservation Board Alcoholic Beverage Control Board Animal Services Advisory Board Arts Commission Board of Health Board of Social Services Carrboro Board of Adjustment Carrboro Northern Transition Area Advisory Committee Carrboro Planning Board Carrboro Recreation and Parks Commission Chapel Hill Board of Adjustment Chapel Hill Library Board of Trustees Chapel Hill Parks and Recreation Commission Chapel Hill Planning Board Chapel Hill/Orange County Visitors Bureau Climate Control Board Commission for the Environment Durham Technical Community College Board of Directors Economic Development Advisory Board Efland-Mebane SAP Implementation Focus Group Equalization and Review Board Hillsborough Board of Adjustment Hillsborough Planning Board Historic Preservation Commission Historic Rogers Road Task Force (CURRENTLY NOT ACCEPTING APPLICATIONS) Hollow Rock Park Planning Committee Homestead & H.S. Roads Safety Task Force Human Relations Commission Hyconeechee Regional Library (Currently not accepting applications) Interlocal Agreement Committee for the Hillsborough Area-Orange County Strategic Growth Plan Phase II IP (Intergovernmental Parks) Work Group Joint Orange Chatham Community Action Agency Jury Commission Mebane Board of Adjustment Mebane Planning Board Nursing Home Community Advisory Committee Orange County Board of Adjustment Orange County Emergency Services Work Group (CURRENTLY NOT ACCEPTING APPLICATIONS) Orange County Housing Authority Orange County Parks and Recreation Council Orange County Planning Board Orange Unified Transportation Board Orange Water & Sewer Authority Board of Directors Orange-Chatham Justice Leadership Council Orange-Person-Chatham Area Programs Board Personnel Hearing Board Piedmont Food & Agricultural Processing Center Steering Committee Solid Waste Advisory Board Ten (10) Year Plan to End Homelessness Executive Team Workforce Development Board - Regional Partnership

Please list work, volunteer and educational experience.
Also provide a brief statement outlining why you wish to serve on the Advisory Boards, Commissions, or Committees you have indicated.

Work Experience:

Volunteer Experience:

Education:

Other Comments:

How did you become aware of Orange County volunteer opportunities?

- County Web Site Current Orange County Volunteer Newspaper Radio TV Other

If Other, how?

ETHICS GUIDELINES FOR COUNTY ADVISORY BOARDS AND COMMISSIONS

By submitting this electronic application, I pledge that, if appointed, I will 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.
  

Applications will be purged after two years from date of application.  You may reapply if still interested in serving on a board and have not yet been appointed.