2. Date*

4. Town of Nags Head Boards and Committees Application

6. This application requests some general information in applying for a position on a Town of Nags Head board or committee. Applications must be submitted to the town clerk at least 15 days prior to appointment.

8. First Name*
9. Last Name*
11. Nags Head Property Address*
12. Years of Residence in Nags Head*
14. Mailing Address*
16. City*
17. State*
18. Zip Code*
20. Phone Number*
22. Email Address (Most communication will be through email.)*
24. Occupation *
25. Employer *
29. I am interested in serving on:*

    1. Planning Board
    2. Board of Adjustment
    3. Personnel Grievance Panel
    4. Dangerous Animal Appeal Board
    5. Arts and Culture Committee
    6. Pedestrian Project Advisory Committee (Ad hoc, temporary committee)
31. What is your interest in serving on this board or committee?*
33. The particular attributes, skills, experience, training, etc. that you have that would be useful in the work of this board or committee:*
35. Relevant Roles in Community - Professional/Civic Activities *
37. Are there any possible conflicts of interest that would prevent you from fairly and impartially discharging your duties as an appointee of the Town board or committee?*

    1. No
    2. Yes (If yes, please explain the possible conflict below.)
39. Possible Conflict Explanation

43. I certify that the facts contained in this application are true and correct to the best of my knowledge and belief. I understand this application will be retained in the Town of Nags Head's Office of the Town Clerk for two years and must be updated after that time. If not updated after that time, the application will be removed from the active consideration file.

45. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field