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2. Legal Name*
3. Preferred Name
5. Email Address*
6. Phone Number*
8. Physical Address*
10. City*
11. State*
12. Zip Code*
14. Do You Live?*

    1. Inside Town Limits
    2. Within Extraterritorial Jurisdiction
15. How Long Have You Resided At This Address*
17. Mailing Address*
19. City*
20. State*
21. Zip Code*
23. Please Select the Board of Commissions on which you wish to serve:*

    1. Alcohol Beverage Commission (ABC) Board
    2. Planning Board
    3. Board of Adjustment

    1. Downtown Pittsboro Advisory Board (PDAB)
    2. Parks and Recreation Advisory Board (PARAB)
    3. Other (Write In)
25. Enter other Board/Commission Here.
27. Why do you wish to serve on the selected Advisory Board(s) or Commission(s)?*
29. Please list any government or nonprofit board, committee, or commission on which you currently serve:*

    Enter "N/A" if not applicable.

31. Please list any experience or education that you believe qualifies you for the position you are seeking:
33. Attendance Commitment *

    As defined by the Code of Ordinances of the Town of Pittsboro, attendance at board/commission meets is a requirement for this appointment. Are you able to commit to this requirement?

    1. YES

    1. NO
35. Additional Information - Optional

    Please feel free to provide any other information you believe may be helpful to the Mayor and Board of Commissioners.

37. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
39. Electronic Signature*
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field