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2. Check all Boards/Committees/Commissions for which you would be willing to serve.*

   1. ABC Commission
   2. Aging Advisory Council
   3. Citizens Advisory Council
   4. E-911 Commission
   5. Economic Development Commission
   6. EMS Peer Review & Education Committee
   7. Equalization & Review
   8. Fire Commission
   9. Health Board
   10. Historic Preservation Commission
   11. Home Health Advisory Board

   1. Jury Commission
   2. Juvenile Crime Prevention Council
   3. Keep Warren County Beautiful
   4. Local Emergency Planning Committee
   5. Library Board of Trustees
   6. Planning Board
   7. Recreation Commission
   8. Social Services Board of Directors
   9. Voluntary Agricultural Districting Advisory Board
   10. Zoning Board of Adjustment
   11. Potentially Dangerous Dog Committee
4. First Choice*
5. Second Choice
6. Third Choice
8. Give Name of "Fire Tax Board" of Interest. You must reside in tax district to be appointed.
9. Only complete this blank if you are applying for appointment to a Fire Tax Board.
11. Applicants Name*
12. Email Address
14. Residential Address*
16. City*
17. State*
18. Zip Code*
20. Phone Number*
21. Alternate Number
23. Birthdate*
25. Race*

    1. African American
    2. Asian
    3. Caucasian
    4. Indian/Native American
    5. Other
26. Sex*
27. Do you live in Warren County?*

    1. Yes
    2. No
29. Job title
30. Are you presently serving in an elected or appointed position? Please explain:
32. Company / Agency & Address
34. Military experience?
    -- Select One --No Military ExperienceAirforce / Airforce ReserveArmy / Army ReserveCoast Guard / Coast Guard ReserveMarines Corps / Marine ReserveNational GuardNavy / Navy Reserve
35. List your Commissioner district, info available at Elections (252) 257-2114.*
    -- Select One --I - West & East WarrentonII - Six Pound, River & RoanokeIII - Nutbush, Smith Creek & HawtreeIV - Fork, Sandy Creek & ShoccoV - Judkins & Fishing Creek
37. Educational Background:
39. Name & address of high school*
41. Name & address of college attended
42. Degree earned
44. List all past employment and/or volunteer experience you have had which may be beneficial in evaluating your qualifications.

    1. Additional information sent to WCGOV@warrencountync.gov
46. Work experience
48. Volunteer experience
50. How did you become aware of Warren County volunteer opportunities?

    1. Newspaper - Warren Record
    2. Newspaper - Other
    3. Current County Volunteer
    4. Other
51. Date this form completed*
53. I certify by my typed initials that all information given is correct to the best of my knowledge.*
54. NOTE TO APPLICANT: This form is active for six (6) months from date of submission.
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field