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Full Name:    

Last (required)

First (required)

Middle

Address: Home Phone: (required)
  Business Phone:

How long have you been a resident of Santa Clara County?
  Months         Years

In which supervisorial district do you live?
 

District 1
District 2
District 3
District 4
District 5


Occupation:
 

Education:
 

High School Degree
College Degree
Masters Degree
Doctoric Degree
Other


On which Advisory Boards,Commissions or Committees would you like to serve? (Please list in order of preference)
 

Why do you want to become a member of a County Advisory Board or Commisions?
 

Please list your qualifications thought applicable for appointment.
 

Are there any special interests or activites that you wish to bring to attention of the Board of Supervisors?
 

Do you have any obligations that might affect your attendance at scheduled evening meetings?
  No          Yes.
If Yes, please explain below:

This space is provided for any additional information you may have about yourself or the position being sought.
 

Please list three references:
1. Name:
  Address:
  Phone:
      
2. Name:
  Address:
  Phone:
      
3. Name:
  Address:
  Phone:

  

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