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APPOINTMENT TO THE <br /> <br /> COUNTY <br />BOARD OF SOCIAL SERVICES <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip <br />Reappointment: [] YES [] NO <br /> <br />Ifreappointment, date of original appointment <br /> <br />County Commissioner: [] YES [] NO <br />Ethnic Background <br /> <br /> PLEASE RETURN THIS FORM <br />NO LATER THAN AUGUST 1~ 2004 <br /> <br />TO <br /> <br /> NC Division of Social Services <br /> Attn: Jane B. Smith <br /> 325 North Salisbury Street <br /> Mail Service Center #2401 <br />Raleigh, North Carolina 27699-2401 <br /> <br />Courier #56-20-25 <br /> <br /> <br />