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2. Application
   County of Goochland, Virginia Application for County Boards, Commissions, Committees and Authorities
4. All appointments to County Boards and Commissions are made by the Board of Supervisors. Please complete this application in its entirety.
6. Instructions
   Submit your application for consideration by fax to (804) 556-4617, by e-mail to Lisa Beczkiewicz by submitting below or by mail to Deputy Clerk to the Board of Supervisors, Goochland County Administration, P.O. Box 10, Goochland, VA 23063. For additional information regarding this application, contact Lisa Beczkiewicz at (804) 556-5811. A separate application must be submitted for each board/committee you are interested in serving.
8. District
9. Date
   Date
11. First Name
12. Last Name
14. Address1
16. Address2
18. City
19. State
20. Zip
22. Date of Birth
23. Last 4 Digits of SSN
25. Phone Number
26. Cell Number
28. Email Address
30. Are you a resident of the county?

    1. Yes
    2. No
32. Do you own real property within the county?

    1. Yes
    2. No
34. Board/Committee
36. Education
38. Employment and/or volunteer work experience
40. Community Involvement
42. Additional Information
    Please note any special skills such as bilingual, multicultural interaction, youth outreach, etc..
44. Submit Application
    By submitting this application to the Deputy Clerk to the Goochland County Board of Supervisors, I hereby certify all information contained herein is true and complete and I hereby consent to the dissemination of this document to the general public.
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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

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