APPLICATION FOR APPOINTMENT TO A PUBLIC BODY

All appointments are at the discretion of the Accomack County Board of Supervisors.  By submitting this application, you are certifying that the information provided is true and correct to the best of your knowledge.

1

What public body would you like to serve on?

 *

What public body would you like to serve on?

2

Full Name:

 *

Full Name:

3

Physical Address:

 *

Physical Address:

4

Mailing Address:

 *

Mailing Address:

5

Telephone Number:

 *

Telephone Number:

6

EMAIL Address:

 *

EMAIL Address:

7

Are you a resident of Accomack County?

 *

Are you a resident of Accomack County?

Yes

No

8

Are you over 18 years of age?

 *

Are you over 18 years of age?

Yes

No

9

Why are you interested in serving on this public body?

 *

Why are you interested in serving on this public body?

10

List any information that qualifies you for this appointment.

List any information that qualifies you for this appointment.

11

Would a criminal background check indicate that your have been convicted of a felony?

 *

Would a criminal background check indicate that your have been convicted of a felony?

Yes

No

12

Would a crinimal background check indicate that you have been convicted of a misdermeanor involving moral turpitude (any offense involving lying, cheating or stealing) since your 18th birthday?

 *

Would a crinimal background check indicate that you have been convicted of a misdermeanor involving moral turpitude (any offense involving lying, cheating or stealing) since your 18th birthday?

Yes

No

13

Are there any criminal charges or proceedings pending against you?

 *

Are there any criminal charges or proceedings pending against you?

Yes

No

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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