Board / Committee Application

2. Board or Committee Being Applied to*
   -- Select One --Airlie Gardens Foundation Board of DirectorsCape Fear Community College Board of TrusteesCape Fear Museum Advisory BoardCape Fear Public Transportation AuthorityCape Fear Public Utility AuthorityCounty / City Community Relations Advisory CommitteeCounty / City Workforce Housing Advisory CommitteeLower Cape Fear Water and Sewer AuthorityNew Hanover Community EndowmentNew Hanover County ABC BoardNew Hanover County Adult Care Home Community Advisory CommitteeNew Hanover County Airport AuthorityNew Hanover County Commission for WomenNew Hanover County Commission on African American History, Heritage and CultureNew Hanover County Cooperative Extension Advisory CouncilNew Hanover County Examiners of Electricians BoardNew Hanover County Health and Human Services BoardNew Hanover County Hispanic/Latino CommissionNew Hanover County Industrial Facilities and Pollution Control Financing AuthorityNew Hanover County Inspections Department Advisory CouncilNew Hanover County Jury by CommissionNew Hanover County Juvenile Crime Prevention CouncilNew Hanover County Library Advisory BoardNew Hanover County Mechanical Board of ExaminersNew Hanover County Non-County Agency Funding CommitteeNew Hanover County Nursing Home Community Advisory CommitteeNew Hanover County Parks and Recreation Advisory BoardNew Hanover County Planning BoardNew Hanover County Plumbing Board of ExaminersNew Hanover County Special Board of Equalization and ReviewNew Hanover County Tourism Development AuthorityNew Hanover County Zoning Board of AdjustmentParks Conservancy of New Hanover County Inc., Board of DirectorsSoutheastern Economic Development CommissionThe Healing Place of New Hanover County, Inc. Board of DirectorsTrillium Health Resources - Southern Regional Advisory BoardWilmington Regional Film CommissionWilmington-New Hanover Port, Waterway and Beach Commission
4. Community Relations Advisory Committee Categories*
   -- Select One --Business CommunityCivil Rights CommunityEducation CommunityFaith CommunityAt-Large

   What category do you represent in the list of required categories for this committee / board?

6. Workforce Housing Advisory Committee Categories*
   -- Select One --At-LargeBusiness/Education CommunityCape Fear REALTORS RepresentativeDevelopment CommunityFinancial CommunityNon-Profit Housing Community

   What category do you represent in the list of required categories for this committee / board?

8. Board of Mechanical Examiners Categories*
   -- Select One --Class I Journeyman MechanicClass II Journeyman MechanicClass III Journeyman MechanicMechanical contractorNC Registered Mechanical Engineer

   What category do you represent in the list of required categories for this committee / board?

10. Commission on African American History, Heritage & Culture Categories*
    -- Select One --At-largeBusiness communityCivil rights communityEducation communityFaith community

    What category do you represent in the list of required categories for this committee / board?

12. Board of Examiners of Electricians Categories*
    -- Select One --Chief County Electrical InspectorIndependent electrical contractorElectrical contractor nominee by power companyElectrical contractor nominee by NC Assoc. of Electrical Contractors

    What category do you represent in the list of required categories for this committee / board?

14. Health & Human Services Board Categories*
    -- Select One --Licensed PhysicianLicensed DentistLicensed/Registered NurseProfessional EngineerLicensed Social WorkerLicensed PharmacistLicensed OptometristLicensed VeterinarianAt-large/Consumer of Human ServicesLicensed PsychologistLicensed Psychiatrist

    What category do you represent in the list of required categories for this committee / board?

16. Inspections Department Advisory Council Categories*
    -- Select One --Commercial builderElectrical contractorEngineerMechanical contractorPlumbing contractorResidential builderAt-large

    What category do you represent in the list of required categories for this committee / board?

18. Juvenile Crime Prevention Council Categories*
    -- Select One --Faith communityStudent under age 21Juvenile defense attorneyBusiness communityParks & Recreation representativeAt-large

    What category do you represent in the list of required categories for this committee / board?

20. Non-County Agency Funding Committee Categories*
    -- Select One --At-largeEducation (pre-K through 12)Faith-basedSenior/elderBusiness/workforce trainingPublic safety/judicialCultural/recreation

    What category do you represent in the list of required categories for this committee / board?

22. Plumbing Board of Examiners Categories*
    -- Select One --Master PlumberJourneyman Plumber

    What category do you represent in the list of required categories for this committee / board?

24. Special Board of Equalization and Review Categories*
    -- Select One --NC licensed property appraiserAttorney, accountant, or other professionalBusiness ownerEngaged in commercial production of agriculture, livestock, timber, or horticultural products, or a NC licensed real estate brokerSingle-family residential property owner

    What category do you represent in the list of required categories for this committee / board?

26. Tourism Development Authority Categories*
    -- Select One --Owner/manager 150 room or more hotel in Wrightsville BeachOwner/manager hotel in Carolina BeachOwner/manager hotel in Kure BeachOwner/manager 150 room or more hotel in City of WilmingtonOwner/manager less than 150 rooms in City of WilmingtonOwner/manager bed and breakfast facilityOwner/manager company that manages and rents more than 100 vacation rental propertiesTourism attraction representativeWilmington Chamber of Commerce representativeOwner/manager of restaurant

    What category do you represent in the list of required categories for this committee / board?

28. Port Waterway & Beach Commission Categories*
    -- Select One --ShippingCommerce & financeTerminals & industryEnvironmental concernsCounty Representative on the NC Beach, Inlet, and Waterway Association

    What category do you represent in the list of required categories for this committee / board?

30. Appointments*

    Appointments will not be made until AFTER all training is complete. An Ombudsman with the Cape Fear Council of Governments will contact you with next steps.

    1. I understand
32. First Name*
33. Last Name*
35. Email*
36. Home Phone*
38. Cell Phone
39. Business Phone
41. Fax
43. Home Address*
45. City*
46. State*
47. Zip Code*
49. Mailing Address (if different from home address)
51. City
52. State
53. Zip Code
55. Years Living in New Hanover County*
59. Personal information collected below is to assure a cross-section of the community is represented.
61. Gender*

    1. Male
    2. Female
    3. Other
62. Race*
63. Age*
65. Occupation*
67. Applicant's Employer*

    In accordance with Article VI, Sec. 7 of the New Hanover County Personnel Policy, a person currently employed by the agency or department for which this application is made must resign his/her position with New Hanover County upon appointment. Furthermore, the applicant should have no immediate family member employed by such agency or department.

69. Professional Activities
71. Volunteer Activities
73. Why do you wish to serve on this board or committee?*

    Conflict of Interest: If a board member believes they have a conflict or potential conflict of interest on a particular issue, that member should state this belief to the other members of his/her respective board during a public meeting. The member should state the nature of the conflict, detailing that they have a separate, private, or monetary interest, either direct or indirect, in the issue under consideration. The member should then excuse themself from voting on the matter.

75. What areas of concern would you like to see addressed by this committee?
77. Qualifications for serving*
79. Other municipal or county boards / committees on which you are serving*

    If you do not serve on any other municipal board or committee, please indicate “None.”

81. Do you have a family member employed by New Hanover County?*

    1. Yes
    2. No
82. County Employee's Name*
83. What department?*
    -- Select One --911 CommunicationsArboretumBoard of ElectionsBuilding SafetyCape Fear MuseumCommunicationsCommunity Justice ServicesCounty Clerk/Commissoners OfficeCounty Manager's OfficeDiversity & EquityEmergency ManagementEngineeringFacilities ManagementFinanceFire RescueHealth & Human ServicesHuman ResourcesInformation TechnologyLegal & Risk ManagementLibraryParks & GardensPlanning & Land UsePort City UnitedPublic HealthRecycling & Solid WasteRegister of DeedsSenior Resource CenterSheriff's OfficeSocial ServicesSoil & WaterStrategyTaxVeteran's ServicesUnknown/Not Sure
87. List three local personal references and phone numbers
89. Reference 1*
90. Reference 1 Phone*
92. Reference 2*
93. Reference 2 Phone*
95. Reference 3*
96. Reference 3 Phone*
98. Additional comments
100. Upload additional information

     If you need to supply supplemental information, it can be uploaded here. Accepted file types: doc, docx, pdf, xcf, xls, xlsx, txt, rtf, ppt, pptx, jpg, png, gif. Limit of 5 files and 50MB total.

101. Date*
     Date
103. Consent*

     1. √ I understand that any board or committee appointee may be removed without cause by a majority of County Commissioners.
Leave This Blank:


105. 1. Receive an email copy of this form.
106. Email address

     This field is not part of the form submission.

107. Submit

* indicates a required field