Citizen Advisory Committee Application

Human Services Division
Poverty and Homelessness Board
Advisory Group: LEAGUE

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* Name:

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* Address:

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* Phone:

NOTE: Information in this box consisting of home addresses and phone numbers may be exempt from disclosure per ORS 192.502(3).

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* How long have you lived in Lane County?

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* Occupation:

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* Place of Employment:

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* Business Address:

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* Business Phone:

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* Email Address:

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* Is your age over 40?

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