Laserfiche WebLink
ATTACI~iENT I <br /> <br /> SOUTBERN PIEDMONT I~EALTI{ SYSTEm, S AGENCY <br /> Suite 425, One Charlottetown Center <br /> 1300 Baxter Street - P. O. Box 4588 <br /> Charlotte, N.C. 28204 <br /> <br /> PROSPECTIVE MEMBERSHIP QUESTIONNAIRE <br /> <br />A. BIOGRAPHICAL INFORMATION <br /> (Nhere 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 45-6~ 65 & <br /> Over <br /> <br /> 4. Family Income: __Less than $10,000 $15,000-$24,999 <br /> <br /> $10,000-$14,999 $25,000 or more <br /> <br /> 5. Race or Ethnic Group: White Black <br /> Hispanic American Indian <br /> Other, please specify <br /> <br /> 6. Education: 12 years or less 13-16 years 16 years <br /> or more <br /> <br /> Academic Degrees (e.g., B.A., B.S., M.A., etc.) <br /> <br /> Handicapped: Yes No Please Specify <br /> <br /> 7. List Majo~ Organizetional Memberships: <br /> <br /> 8. I am interested in serving on the: <br /> <br /> Governing Body - Proposed Use of Federal Funds Review Committee <br /> Plan Development Public Information & Edncation Committee <br /> <br /> Project Review__ Plan Implementation Committee <br /> <br /> A Technical Advisory Committee __ Subarea Advisory Council <br /> Nherever I can be of service <br /> <br /> <br />