Application for Rocky/Jerusalem Fire Relief Fund Committee Name: ______________________________________________________________________ Address: ____________________________________________________________________ Telephone (work): __________________________ (personal): ________________________ E-mail: ______________________________________________________________________ Why are you interested in serving on the Rocky/Jerusalem Fi re Reli ef Fund Committee? What background and/or experti se do you have that would benefit the committee? What community activities are you involved with in Lake County? Were you or any of your i mmediate famil y members affected by the Rocky/Jerusalem fire? If so, please explain. (Immediate family is defined to include spouse, domestic partner, parents and grandparents, children and grandchildren, brothers and sisters, mother-in-law, brother-in-law and sister-in-law, daughter-in-law and son-in-law, adopted and step-family members.) Are any of your immedi ate famil y employees of NCO, MendoLake Credit Uni on, or the Lake County Department of Social Services? Are you able to travel to meetings in different locations?Yes | No Are you able to attend daytime meetings? Yes | No Is there anything el se you would like to tell us about yourself? North Coast Opportunities, MendoLake Credit Union, and the Lake County Department of Social Services have teamed up to create a fund for those affected by the Rocky/J erusalem fires. The fund will be managed by the Rocky/J erusalem Fire Relief Fund Committee, which will consist of seven members: two representatives from NCO, one each from MLCU and LCDSS, and three Lake County community members. Those affected by the fire can apply for assistance, and the committee will determine how to distribute the funds. By signing below, I certify that if chosen to serve on the committee, I will: Make every effort to attend all committee meetings. Be objective when helping to decide where to allocate funds. Participate in a democratic processMaintain confidentiality regarding all applications, discussions, and decisions Appli cant signature: __________________________________________________________ Printed name: _______________________________________________________________ Date: ______________________________________________________________________ Please return completed applications to NCO Executive Assistant Elizabeth Archer earcher@ncoinc.org | 413 N State Street, Ukiah CA 95482 | (707) 467-3210