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C ;. <br />08110 <br />APPLICATION FOR HAWAII COUNTY BOARDS AND COMMISSIONS <br />Our goal, in addition to meeting State and County regulations regarding the composition of a particular board or <br />commission, is to select members who bring a variety of skills and late experiences to these agencies. The answem to the <br />following questions can assist us in these efforts, <br />NAME DATE <br />Last First - Middle <br />RESIDENCE ADDRESS <br />-- - City State Zip <br />MAILING ADDRESS <br />- City State Zip <br />PHONE <br />Home Business Dell Fax <br />E -MAIL <br />U.S. CITIZEN ❑ Yes [3 No HAWAII COUNTY VOTER (] Yes No COUNCIL DISTRICT <br />(Call 961-8277 if not sure) <br />DATE OF *SOCIAL LENGTH OF RESIDENCE <br />BIRTH SECURITY NO. IN HAWAII <br />MARRIED [:]Yes ❑ No NAME OF SPOUSE <br />EDUCATION <br />EMPLOYMENT RECORD (Past ten years) <br />FROM (Year) TO (Year) EMPLOYER <br />OCCUPATION <br />Are you currently serving on any federal, state or county board or commission? ❑ Yes ❑ No <br />If yes, name the entity and date your term ends: <br />List by preference the board or commission you wish to serve on: <br />1. 3. <br />2. 4. <br />Briefly explain your interest in being a member of a particular board or commission. <br />Are you currently an official and/or card carrying member of any political party? C]Yes El No <br />Ifyes,' what polrfical party? <br />