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· SOUTHERN PIEDMONT ttEAL~H SYSTEMS AGENCY <br /> Suite 425 - One Charlottetown Center <br /> 1300 Baxter Street - P. O. Box 4588 <br /> Charlotte, NC 28204 <br /> <br /> PROSPECTIVE MEMBERSHIP QUESTIONNAIRE <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 /> Telephone: Home Business <br /> <br /> 2. Sex: Male Female <br /> <br /> 3. Age Group: __ 18~34__ 35-44 45-64 __ 65+ <br /> <br /> 4. Family Income: Less than $10,000 $15-24,999 <br /> $10-14,999 $25,000+ <br /> <br /> 5. Race or Ethnic Gronp: White Black <br /> Hispanic American Indian <br /> Other, please specify <br /> <br /> 6. Education: less than 12 years 12 years/HS or GED Diploma <br /> <br /> 13 to 15 years 16 years or more <br /> <br /> Academic Degrees [e.g., BA~ BS, MA, etc.] <br /> <br /> 7. Handicapped: Yes No Please specify <br /> <br /> 8. List Major OEganizational Memberships: <br /> <br /> 9. I am interested in serving on the: <br /> <br /> Governing Body Review Committee [PUFF & Project] <br /> Pla~ Development Public Education Committee <br /> <br /> Pla~ Implementation Committee <br /> <br /> County Implementatio~ Group <br /> <br /> A Technical Advisory Committee <br /> Subarea Advisory Council <br /> Wherever I can be of service <br /> <br /> <br />