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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: vv;tVa L. (~ /\.1 t~ C e-I <br />(If married, please g ve spou e's first name t) <br /> <br />10S Durb(f/ ~-fV'..eL-t <br />Residence Street Address <br /> <br />Martinsville, VA 24112 <br /> <br />,C; CL V'Yl-~ c.t S ,,~e5 ;, (/tc (;L Lz__ <br />Mailing Address <br /> <br />City <br /> <br />Zip Code <br /> <br /> <br />TELEPHONE NUMBER: <br /> <br /> <br />considered for <br />qualifications <br />cI <br /> <br />vel.. ~/~k VS <br /> <br />(O\J[\~ <br /> <br />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) :~~/O~ <br />