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CITY OF MARTINSVILLE INFORMATION FORM <br /> <br /> FOR APPOINTMENT TO CITY BOARDS, COMMISSIONS AND COMMITTEES <br /> ***Please Print or Type All Answers*** <br /> <br /> (If married, please give spouse's first name ?) <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 27& · ~_T2-~.Z(~O <br /> <br />Business <br /> <br />OCCUPATION/EMPLOYER NAME:. ~,~ ~-~¢~.~-~. <br />REFERENCE: <br /> <br />CHOICE OF COMMITTEE:~)~i~;~F,y/ <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 />~-~ ~ ~-,~ ~. (please continue on back) <br /> <br />RETURN TO: Clerk of Council, P. O. Drawer 1112, Martinsville, VA <br />24114, NO LATER THAN . <br /> <br />Date Received (to be completed by Clerk of Council): <br /> <br /> <br />