PART I - State Corporation Commission
|PART I |
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|Advisory Committee Position Applied for: |
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|Term: |
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|Nominating Self: Yes No |
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|Nominated By: |
|PART II |
|Name: |Email: |
|Address: |Telephone Numbers |
| |Home ( ) |
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| |Business ( ) |
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| |Fax ( ) |
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| |Cell ( ) |
|Education: |
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|Business Experience: |
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|PART II (continued) |
|Present Title and Job Description: |
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|Name and Address of Current Employer: |
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|Specific Damage Prevention Experience: |
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|Membership on Other Committees, Previous and Current: |
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|Other Pertinent Activities: |
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|Please list the name, address, telephone number, and relationship to the applicant of at least three references. |
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|The Advisory Committee meets monthly. Do you have any concerns regarding this time commitment? |
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|Yes No |
|PART III |
|Please explain your view of Virginia’s Damage Prevention Program: |
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|How can we further improve damage prevention in our Commonwealth? |
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|PART IV |
|Candidate Signature: | |
| |Date: |
| | |
|Nominator Signature: | |
| |Date Application |
|____________________________________ |Received:________________________ |
|A Resume may be attached, if desired. |Resume Attached: Yes No |
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