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SOUTHERN PIEDMONT HEALTH SYSTEMS AGENCY <br /> Suite 425 - One Charlotteto~n Center <br /> 1300 Baxter Street P.O. Box 35588 <br /> Charlotte, NC 28235 <br /> <br /> GOVERNING BODY NOMINATION FORM <br /> <br />A. BIOGRAPHICAL INFORMATION <br /> [Where blanks appear, please check the appropriate response.] <br /> <br /> 1. Name [Please print] <br /> Business Address <br /> Employer Name/OccuPation/Profession/Title <br /> <br /> Home Address <br /> <br /> Telephone: Home Business <br /> <br /> 2. Sex: Male Female <br /> 3. Age Group: 18-34__ 35-44 45-64 65+ <br /> <br /> 4. Family Income: Less than $10z000 $15-24/999 <br /> $10-14,999 $25,000+ <br /> <br /> 5. Race or Ethnic Group: white Black <br /> Hispanic American Indian <br /> Others please specify <br /> <br /> 6. Education: less than 12 years 12 years/HS or GEO Oiploma <br /> <br /> 13 to 15 years 16 years or more <br /> <br /> Academic Degrees [e.g.t BA, BSs MA, etc.] <br /> <br /> 7. Handicapped: Yes No Please specify <br /> <br /> 8. List Major Organizational Memberships: <br /> <br /> 9. I am interested in serving on the: <br /> <br /> Governing Body Review Committee <br /> PLan Develop~nent Public Education Committee <br /> <br /> Plan Implementation Committee <br /> County Implementation Group <br /> A Technical Advisory Committee <br /> Subarea Advisory Council <br /> Wherever I can be of service OVER <br /> <br /> <br />