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2. UPON COMPLETION PRESS SUBMIT OR RETURN TO:

   Clerk to the Board of Supervisors 547 Market Street, Suite 102 Colusa, CA 95932 (530) 458-0508 boardclerk@countyofcolusaca.gov

4. NAME OF COMMITTEE/COMMISSION/DISTRICT/OTHER:
6. NAME OF APPLICANT:
8. LIST YOUR PHYSICAL AND MAILING ADDRESS IF DIFFERENT:
10. Address1
12. Address2
14. City
15. State
16. Zip
18. PHONE:
19. E-MAIL:
21. SUPERVISORIAL DISTRICT:

    If you do not know your Supervisorial District please note, or list your County Supervisor’s name.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
23. LIST ANY QUALIFICATIONS AND/OR REASONS YOU WISH TO SERVE ON THIS COMMITTEE:
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

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