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*RECEIVEO 2 -20lB <br /> CITY OF MARTINSVILLE INFORMATION FORM <br /> FOR APPOINTMENT TO CITY BOARDS, COMMISSIONS AND COM}{ITTEES <br /> ***Please Print or Type Ail Answers*** <br /> <br /> (If married, please give spouse's first / -- name t ) <br /> <br />Residence Street Address <br /> <br />Martinsville, VA 24112 <br />Mailing Address <br /> <br />City <br /> <br />TELEPHONE NUMBER: <br /> <br /> Zip Code <br />Home ~7~: /~/~ ~- ~/0q/ <br /> <br />Business <br /> <br />OCCUPATION/EMPLOYER NAME:_ <br /> <br />CHOICE OF COMMITTEE: ~C~cO/ ~ <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 />Po <br /> <br /> (please continue on back) <br />Drawer 1112, Martinsville, VA <br /> <br />Date Received (to be completed by Clerk of Council): <br /> <br /> <br />