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2. Please list in order of preference the Boards and Commissions for which you would be willing to serve
4. 1.
5. 2.
7. 3.
8. Any / All Boards / Committees

   1. Check if applicable
10. Note:
    By applying for the above listed Boards and Commissions, I have no known apparent or potential conflict of interest.
12. If you are responding to a specific criteria for a position, please explain further:
14. First Name*
15. Last Name*
17. Date of Birth*
18. Sex
19. Race
21. Residence Address*
23. City*
24. State*
25. Zip Code*
27. Mailing Address
    (If different)
29. City
30. State
31. Zip Code
33. Home Phone Number
34. Work Number
35. Fax Number
37. Employer
39. Job Title
41. Email Address
43. Do you live within the extraterritorial jurisdiction of a municipality?

    1. Yes
    2. No

    (The extraterritorial jurisdiction is the area just outside the city limits of a municipality)
45. Please list your County Commissioner District.
    (This information can be obtained from the Board of Elections at Phone: 252-902-3300)
47. Educational Background:
49. High School Attended
51. Address
53. City
54. State
55. Zip Code
57. College Attended
59. Address
61. City
62. State
63. Zip Code
65. Degree(s) Received
67. Please list any military experience.
69. If you are presently serving as an elected or appointed offical, please explain.
71. Please list all past employers and volunteer experience you have had which may be beneficial in evaluating your qualifications.
73. Work Experience
75. Volunteer Experience
77. Pitt County Citizen Academy Graduate?

    1. Yes
    2. No
79. How did you become aware of Pitt County volunteer opportunities?

    1. Newspaper
    2. Current Pitt County Volunteer
    3. Radio
    4. TV
    5. Other

    (Please check the appropriate response)
81. If other, please explain.
83. If I am appointed to serve on one or more boards, I will agree by signing an Affirmation of Understanding, to attend the required amount of meetings each calendar year and not to exceed unexcused absences by more than 25%, or three (3) meetings in any calendar year.
85. Electronic Signature
86. Date
    Date
88. Please feel free to attach a resume if desired.
90. Note
    When applying for a Pitt County Board or Commission, your application is considered a public record. The Board Appointment policy requires that applications be on file in the Clerk's Office 15 days prior to consideration for appointment.
    
    Interest to Serve forms remain current for two full years. Following that, the applicant may wish to contact the Clerk to the Board's Office for an updated form.
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field