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2. 
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Home Phone Number*
14. Business Phone Number
16. Cell Phone Number
17. Email Address*
21. Occupation
23. Retired From
25. How did you hear about this opportunity?
27. Are you currently serving on a county board or committee?

    1. Yes
    2. No
28. If so, please identify the board or committee.
    -- Select One --Adult Care & Nursing Home Community Advisory CommitteeAnimal Advisory BoardBlue Ridge Community ActionBoard of Equalization and ReviewBoard of HealthBurke Co. Board of AdjustmentBurke Co. Planning BoardBurke Development IncChild Protection Child Fatality Prevention TeamCouncil on AgingDrexel Planning Board (ETJ)EMS Peer Review CommitteeEMS Quality Management CommitteeFoothills Regional Airport AuthorityHickory Regional Planning CommissionIndustrial Revenue Bond BoardJury CommissionJuvenile Crime Prevention CouncilJuvenile Crime Prevention Council - Oversight "Governance" CommitteeLibrary Board of TrusteesLocal Emergency Planning CommitteeMorganton Board of Adjustment (ETJ)Morganton Planning Board (ETJ)Partners Behavioral Health ManagementRecreation CommissionRegional Aging Advisory CommitteeRutherford College Planning Board & Board of Adjustment (ETJ)Senior Center (EB) Advisory BoardSenior Center (Morg.) Advisory BoardSmart Start (Burke Partnership for ChildrenSocial Services BoardTourism Development AuthorityTransportation Advisory CommitteeTransportation Coordinating CommitteeVeterans Service BoardVolunteer Agriculture BoardWestern Piedmont Community College Board of TrusteesWestern Piedmont Council of Government - Policy Board: AlternateWestern Piedmont Council of Government - Policy Board: Delegate
30. Please indicate any community interests and activities that you are involved in.
32. Do you reside in the extraterritorial area of a municipality?

    1. Yes
    2. No
36. List in order of preference the board and/or committee(s) on which you would like to serve.
38. First Choice*
    -- Select One --Adult Care & Nursing Home Community Advisory CommitteeAnimal Advisory BoardBlue Ridge Community ActionBoard of Equalization and ReviewBoard of HealthBurke Co. Board of AdjustmentBurke Co. Planning BoardBurke Development IncChild Protection Child Fatality Prevention TeamCouncil on AgingDrexel Planning Board (ETJ)EMS Peer Review CommitteeEMS Quality Management CommitteeFoothills Regional Airport AuthorityHickory Regional Planning CommissionIndustrial Revenue Bond BoardJury CommissionJuvenile Crime Prevention CouncilJuvenile Crime Prevention Council - Oversight "Governance" CommitteeLibrary Board of TrusteesLocal Emergency Planning CommitteeMorganton Board of Adjustment (ETJ)Morganton Planning Board (ETJ)Partners Behavioral Health ManagementRecreation CommissionRegional Aging Advisory CommitteeRutherford College Planning Board & Board of Adjustment (ETJ)Senior Center (EB) Advisory BoardSenior Center (Morg.) Advisory BoardSmart Start (Burke Partnership for Children)Social Services BoardTourism Development AuthorityTransportation Advisory CommitteeTransportation Coordinating CommitteeVeterans Service BoardVolunteer Agriculture BoardWestern Piedmont Community College Board of TrusteesWestern Piedmont Council of Government - Policy Board: AlternateWestern Piedmont Council of Government - Policy Board: Delegate
40. Second Choice
    -- Select One --Adult Care & Nursing Home Community Advisory CommitteeAnimal Advisory BoardBlue Ridge Community ActionBoard of Equalization and ReviewBoard of HealthBurke Co. Board of AdjustmentBurke Co. Planning BoardBurke Development IncChild Protection Child Fatality Prevention TeamCouncil on AgingDrexel Planning Board (ETJ)EMS Peer Review CommitteeEMS Quality Management CommitteeFoothills Regional Airport AuthorityHickory Regional Planning CommissionIndustrial Revenue Bond BoardJury CommissionJuvenile Crime Prevention CouncilJuvenile Crime Prevention Council - Oversight "Governance" CommitteeLibrary Board of TrusteesLocal Emergency Planning CommitteeMorganton Board of Adjustment (ETJ)Morganton Planning Board (ETJ)Partners Behavioral Health ManagementRecreation CommissionRegional Aging Advisory CommitteeRutherford College Planning Board & Board of Adjustment (ETJ)Senior Center (EB) Advisory BoardSenior Center (Morg.) Advisory BoardSmart Start (Burke Partnership for Children)Social Services BoardTourism Development AuthorityTransportation Advisory CommitteeTransportation Coordinating CommitteeVeterans Service BoardVolunteer Agriculture BoardWestern Piedmont Community College Board of TrusteesWestern Piedmont Council of Government - Policy Board: AlternateWestern Piedmont Council of Government - Policy Board: Delegate
42. Third Choice
    -- Select One --Adult Care & Nursing Home Community Advisory CommitteeAnimal Advisory BoardBlue Ridge Community ActionBoard of Equalization and ReviewBoard of HealthBurke Co. Board of AdjustmentBurke Co. Planning BoardBurke Development IncChild Protection Child Fatality Prevention TeamCouncil on AgingDrexel Planning Board (ETJ)EMS Peer Review CommitteeEMS Quality Management CommitteeFoothills Regional Airport AuthorityHickory Regional Planning CommissionIndustrial Revenue Bond BoardJury CommissionJuvenile Crime Prevention CouncilJuvenile Crime Prevention Council - Oversight "Governance" CommitteeLibrary Board of TrusteesLocal Emergency Planning CommitteeMorganton Board of Adjustment (ETJ)Morganton Planning Board (ETJ)Partners Behavioral Health ManagementRecreation CommissionRegional Aging Advisory CommitteeRutherford College Planning Board & Board of Adjustment (ETJ)Senior Center (EB) Advisory BoardSenior Center (Morg.) Advisory BoardSmart Start (Burke Partnership for Children)Social Services BoardTourism Development AuthorityTransportation Advisory CommitteeTransportation Coordinating CommitteeVeterans Service BoardVolunteer Agriculture BoardWestern Piedmont Community College Board of TrusteesWestern Piedmont Council of Government - Policy Board: AlternateWestern Piedmont Council of Government - Policy Board: Delegate
46. Most board or committee seats have no special requirement other than being a citizen of Burke County. Do you have special criteria that you would like to be considered for this appointment?
48. Describe why you are interested in serving on a board or committee. What goals and objectives do you have?
50. Are you willing to attend board or committee meetings on a regular basis?

    1. Yes
    2. No
52. Please disclose any business or personal relationships that may be considered a conflict of interest if selected to serve on a board or committee.
54. Optional Remarks
56. Optional - Click here to upload supporting documentation that you wish to be reviewed alongside your application.

58. Burke County is committed to providing an inclusive and welcoming environment for everyone and does not and shall not discriminate on the basis of race, color, religion or creed, gender, gender expression, age, national origin or ancestry, disability, marital status, sexual orientation, or military status, in any of its activities or operations.

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60. 1. Receive an email copy of this form.
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