Name               

Home Address 

                    City     State   Zip 

Phone      Work     Home

Place of Employment

Job Title

We ask your help in assuring diversity of membership by age, gender, and race by answering the following questions:

Check one:        Male          Female

Ethnic Background: 

Check one:  African American         Caucasian     Hispanic     Other

Physically impaired?      Check one:  Yes            No

Date of birth 

Please check any of the following Boards / Commissions on which you would like to serve.  If you would like information on what these committees do, contact Town Clerk Jane Jones at (804) 575-4220 or send an email.  

South Boston Planning Commission

South Boston Industrial Development Authority

South Boston - Halifax County Regional Library Board

Parks & Recreation Advisory Committee

Transportation Safety Commission

Halifax County Improvement Council

Southside Planning District Commission

South Boston Board of Zoning Appeals

Lake Country Development Corporation

Southside Regional Partnership

Halifax Economic Development Council

Board of Viewers

Cornerstone

Please list any work, volunteer, and/or educational experience you would like to have considered.

Work Experience        

Volunteer Experience     

Educational Experience

Other Comments