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'03/12/2020 14:04 540G325410 <br />FROf'I :CITY I:]F' I~IRTINSUILLE <br /> <br /> ELTTE HC <br />F¢.X NO. : $40-¢:~6-$280 <br /> <br /> PAGE 02 <br />Jun. 11 ~1 11:4~M P2 <br /> <br />(If married, please <br /> <br />Residence Street Address <br /> <br />Xar'c. insviLZeo VA 24112 <br /> <br />Nailinq Address <br /> <br />PLFJ~E PRIRT OR TYPE HERB why ~fou vculd like to be oonsidere~ £or <br />appoin~ment ~o ~is comittee and wha2 ~ti~lar ~alifi~iens <br />you ~eel you Waver <br /> ..... <br /> <br />(please continue on baok) <br /> <br />RB~q~l ~: Clerk of Council, P. O. Occur 1112, N~rtt~svlile, VA <br />24114, Re IdtT~TR~ . <br /> <br />Date Received (~o be completed b~ Clerk <br /> <br /> <br />