Name:_____________________________________ Work Phone: _________________
 

Address: ___________________________________ Home Phone: _________________
 

City: ________________________________ State: _______ Zip Code: _____________
 

County of residence: _____________________________________ Date: ___________
 

Education: ______________________________

Category of Representation (check one)

__ County Government

 __ SCD

__ Other

 __ Member at Large
 

Name and address of employer: _____________________________________________
 

_______________________________________________________________________
 

Duties and responsibilities: _________________________________________________
 

Special skills and training: _________________________________________________
 

Personal interests, hobbies: _________________________________________________
 

Is there any particular area of RC&D activity or project that you would be interested in becoming a part of as you serve on the Council? (Strategic planning, resource issues, an officer, etc.):
 

________________________________________________________________________
 

Other civic, professional organization membership/affiliation:
 

________________________________________________________________________
 

Other comments or suggestions:______________________________________________
 

________________________________________________________________________