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2. Current Action Circles
   1. Farming and Economic Development 2. Food Security
4. Any / All Boards / Committees

   1. Check if applicable
6. Note:
   By applying to be a part of an Action Circle, I have no known apparent or potential conflict of interest.
8. First Name*
9. Last Name*
11. Date of Birth*
12. Sex
13. Race
15. Residence Address*
17. City*
18. State*
19. Zip Code*
21. Mailing Address
    (If different)
23. City
24. State
25. Zip Code
27. Home Phone Number
28. Work Number
29. Fax Number
31. Email Address
33. Do you agree to make the time commitment to be an active member?

    1. Yes
    2. No
35. Will you recuse yourself from discussion topics if you have a conflict of interests?

    1. Yes
    2. No
37. In which Action Circle will you participate?

    1. Food Security
    2. Farming and Economic Development
39. If representing an organization, which one?
41. How do you see yourself being helpful to the Action Circle’s work in 2017?
43. How did you become aware of Action Circle opportunities?

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

    (Please check the appropriate response)
45. Date
    Date
47. PLEASE NOTE:
    When applying for an Action Circle, your application is considered a public record.
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49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

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