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Date of Application:

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Date of Application:

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Contact Info

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Contact Info

First Name:

Middle Initial:

Last Name:

Mailing Street Address:

Physical Street Address:

Preferred Phone #:

Email Address:

Pinehurst Resident Since:

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Are you a registered voter living in Pinehurst? 

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Are you a registered voter living in Pinehurst?

Yes

No

4

Have you ever run for elected office? 

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Have you ever run for elected office?

Yes

No

5

If so, when, where, and which office?

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If so, when, where, and which office?

6

If elected, how long did you hold that position? 

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If elected, how long did you hold that position?

7

Do you have any close relatives employed by The Village of Pinehurst? If so, please state their name and your relationship to them. 

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Do you have any close relatives employed by The Village of Pinehurst? If so, please state their name and your relationship to them.

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Why do you want to serve the Village of Pinehurst as a Councilmember?

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Why do you want to serve the Village of Pinehurst as a Councilmember?

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What qualifications do you have that would be relevant to your service as a Councilmember?

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What qualifications do you have that would be relevant to your service as a Councilmember?

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What issues would you like the Village Council to address? 

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What issues would you like the Village Council to address?

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Summarize your educational background, volunteer experience, work experience, or any additional information that you believe would be relevant to the Village Council's consideration of your candidacy.  

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Summarize your educational background, volunteer experience, work experience, or any additional information that you believe would be relevant to the Village Council's consideration of your candidacy.

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I certify that all statements made by me on this application are true and complete to the best of my knowledge.  I understand that any false statement, misrepresentation, or omission may cause me to be excused from service.

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Please initial for certification.

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STATE OF NORTH CAROLINA

COUNTY OF MOORE

RELEASE AND ACKNOWLEDGEMENT

The undersigned applicant is an adult person of sound mind who wishes to serve the Village of Pinehurst as a Council Member.

The applicant has read this document thoroughly and there are no other agreements, oral, or written, which are inconsistent with this document.

The applicant understands this application and all the information contained in it shall be a public record. 

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STATE OF NORTH CAROLINA COUNTY OF MOORE RELEASE AND ACKNOWLEDGEMENT The undersigned applicant is an adult person of sound mind who wishes to serve the Village of Pinehurst as a Council Member. The applicant has read this document thoroughly and there are no other agreements, oral, or written, which are inconsistent with this document. The applicant understands this application and all the information contained in it shall be a public record.

Date

Please initial for release and acknowledgement.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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