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CITY OF MARTINSVILLE INFORMATION FORM <br /> <br />FOR APPOINTMENT TO CITY BOARDS, COMMISSIONS AND COMMITTEES <br /> <br /> ***Please Print or Type Ail <br />NAME' ~'~'f/~ ~_-. (.X.,/y.'~ 7- 7-- / <br />(If ~arried?please give spouse's first name <br /> <br />Residence Street Address <br /> <br />Answers*** <br /> <br /> ~) <br /> <br />Martinsville, VA 24112 <br /> <br />Mailing Address <br /> <br />City Zip Code <br />TELEPHONE NUMBER: Home <br />Business <br /> <br />iF- <br /> <br />OCCUPATION/EMPLOYER NAME <br /> <br />REFERENCE: ~, ~) ~ ~ ~/a $ <br /> <br />c oicE OF CO ITTEE: <br /> <br />PLEASE PRINT OR TYPE HERE why you would like to be considered for <br />appointment to this committee and what particular qualifications <br />you feel you have: <br /> <br />RETURN TO: Clerk of Council, <br />24114, NO LATER THAN <br /> <br /> (please continue on back) <br /> <br /> P. O. Drawer 1112, Martinsville, VA <br /> <br />(to be completed by Clerk of Council): <br /> <br />Date Received <br /> <br /> <br />