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SOUTHERN PIEDMONT HEALTH SYSTEMS AGENCY <br /> Suite 425 One CharlottetOWn Center <br /> 1300 Baxter Street P.O. Box 35588 <br /> Charlotte, NC 28235 <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 /> B~siness Address: <br /> Employer Name/Occupation/Profession/T~tle <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 Group: 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 MajoriOrganizational Memberships: <br /> <br /> 9. I am interested in serv'ing on the: <br /> <br /> Governing Body Review Committee [PUFF & Project] <br /> <br /> Plan Development __ Public Education Committee <br /> <br /> Plan Implementation Committee <br /> <br /> __ County Implementation Group <br /> <br /> __ A Technical Advisory Committee <br /> <br /> __ Subarea Advisory Council <br /> <br /> Wherever I can be of service <br /> OVER <br /> <br /> <br />