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2. First Name & Middle Initial
3. Last Name
5. Gender
6. Race
7. Birthdate
   Birthdate
9. Email
10. Phone
11. Additional Phone
13. Address
15. City
16. State
17. Zip Code
19. Do you live in Winston-Salem City limits?

    1. Yes

    1. No
20. Do you live in Forsyth County?

    1. Yes

    1. No
22. Are you a graduate of the City of Winston-Salem University?

    1. Yes

    1. No
23. What year did you graduate?
27. Education

    1. High School
    2. College
    3. Graduate School
    4. Other
28. Please List
29. School Name/Years Attended
31. Degree & Subject of Study
33. Current Employer Name
34. Job Title
38. Applying for Board/Commission ( Enter One):
39. What Board or Commission are you currently serving?
    Please include expiration date.
41. Why are you interested in serving on that Board/Commission?
43. Are you willing to serve on any other Board/Commission?

    1. Yes
    2. No
44. Please List
46. Are you interested in serving in any other community volunteer activities?

    1. Yes
    2. No
47. Please List
49. Interests/Skills/Areas of Expertise/Professional Organizations
53. List Two Professional References
55. First Name
56. Last Name
58. Address
60. City
61. State
62. Zip Code
64. Phone
65. Relationship
69. First Name
70. Last Name
72. Address
74. City
75. State
76. Zip Code
78. Phone
79. Relationship
83. Affirmation of Eligibility
85. Is there any possible conflict of interest or other matter that would create problems or prevent you from fairly and impartially discharging your duties as an appointee to a Board/Commission?

    1. Yes

    1. No
87. Please Explain
89. I understand this application is public record, and I certify the facts contained in this application are true and correct to the best of my knowledge. I authorize and consent to background checks and to the investigation and verification of all statements contained herein. I further authorize all information concerning my qualifications to be investigated and release all parties from all liability for any damages that may result from this investigation. I understand and agree any misstatement or conduct will be cause for my removal from any board or commission.
91. Signature
92. Date
    Date
94. Return Completed Form
    Mayor’s Office
    P.O. Box 2511
    Winston- Salem, NC 27102
    Phone: 336-727-2058
    Fax: 336-748-3241
    Email the Mayor's Office
    
    Please include your resume when submitting your application.
96. Note: Applications will be kept on file for two years from the date of application.
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit Submit and Print

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