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2. 

3. Halifax County Board of Supervisors
   1050 Mary Bethune Street
   P.O. Box 699
   Halifax, VA 24558

   Citizen Committee Interest Form

5. First Name
6. Last Name
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
15. Email Address
17. Election District
    -- Select One --12345678
18. Education Background
    -- Select One --High School GraduateSome CollegeCollege GraduateAdvanced College Education
20. Occupation
21. Employer
23. Special Skills/Interests/Qualifications that would be a benefit to committee appointed
25. Committees of Interest

    Please mark all that apply.

    1. 501 Coalition
    2. Agricultural Development Advisory Committee
    3. Airport Advisory Commission
    4. Board of Equalization
    5. Board of Zoning Appeals
    6. Building Code Board of Appeals
    7. Danville Community College Board
    8. Southside Community College Board
    9. Halifax County Service Authority
    10. Halifax County Improvement Council

    1. Halifax County Industrial Development Authority
    2. Lake Country Area Agency on Aging
    3. Lake Country Development Corporation
    4. Library Board
    5. Halifax County Planning Commission
    6. Halifax County Recreation Advisory Committe
    7. Social Services Board
    8. Southside Community Services Board
    9. Transportation Safety Commission
    10. Workforce Investment Board
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27. 1. Receive an email copy of this form.
28. Email address

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29. Submit

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