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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 All Answers*** <br /> <br />(If married, please give spouse's first name ~) <br /> <br />Residence Street Address <br />Martinsville, VA 24112 <br /> <br />Mailing Address <br />City <br /> <br />TELEPHONE NUMBER: <br /> <br /> Zip Code <br /> <br /> Home <br /> <br />Business Z$ <br /> <br />OCCUPATION/EMPLOYER NAME: ~,~ ~%c¢c~-/,~-%.. ~,'~e~,¢~'~ ~o~/~;~,'(' <br /> <br />REFERENCE: <br /> <br />CHOICE OF COMMITTEE:W'.~)~~/~.~-¢~'~./~ <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 />~/~.~f.. ~'~ ~/~.,~ ~.~. (please continue on back) <br /> <br />RETURN TO: Clerk of Council, P. O. Drawer 1112, Martinsville, VA <br />24114, NO LATER THAN <br />Date Received (to be completed by Clerk of Council): ~/;~/~ <br /> <br /> <br />