Application to Serve on a Surry County Board/Committee/Commission

District *

Please select the Board, Committee, or Commision of Interest *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Employment, Education & Partnership Information

Job Title *

Employer *

Employer Phone Number *

Employer Address *

City *

State *

Zip Code *

Highest Level of Education *

Civic Activites

Membership in Fraternal, Business, Church or Social Organizations

What is the Reason(s) in which you desire to service on this board, committee, or commission? *

Please check any other Boards, Committees, or Commissions that you have interest in

This application will be kept on file for two years. Thank you for applying. Please visit us on the web at www.surrycountyva.gov