Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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The following qualifies me as a Stakeholder of the WLASNC:

I live within the boundaries of the WLASNC

I own property within the boundaries of the WLASNC (list property address below)

I work within the boundaries of the WLASNC (list work name address below)

I own a business within the boundaries of the WLASNC (list business name and address below)

I am a Community Interest Stakeholder (list community interest organization name and address below)

Property Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business or Community Interest Organization Name and Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I understand that if I am accepted to this Committee position, I will be subject to the WLASNC Bylaws as well as the Brown Act, and that violations of these rules may be grounds for immediate removal from my position. *

Yes

No

Today's Date *

MM

DD

YYYY