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<br />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 />NAME: 71 OY J. fl" vfl /rlr/ <br />(If married,' please give spouse's <br /> <br />~J 07 (J It{- tl;?-Ir- <br />Residence Street Address <br /> <br />/ ..siAJ.1I1 <br />first name t) <br /> <br />Martinsville, VA 24112 <br /> <br />Mailing Address // <br />/11#1t/~$;//;;~ <br />City . <br /> <br />Business <br /> <br />A?~- <br />~1( <br />,)EL~, <br /> <br />'L.j?//2- <br />Zip Code <br />~y~2..6c r <br /> <br />~3 r-/2..~f <br /> <br />j/;d- <br /> <br />TELEPHONE NUMBER: Home <br /> <br />OCCUPATION/EMPLOYER NAME: <br /> <br />REFERENCE: <br /> <br />5c !f?,! <br /> <br />I;~ ",J <br /> <br />CHOICE OF COMMITTEE: <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 />I ~ 1111/" JfI <br /> <br />C.~/a <br /> <br />/.b <br /> <br />/-If <br /> <br />c..,!7. 5)' ~~, <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): IzI2~/DS <br />