COUNTY COUNCIL OF COLLETON COUNTY APPLICATION FOR SERVICE

Colleton County Administration
109 Benson Street
P.O. Box 157
Walterboro, SC 29488
843-549-5221
NAME BOARD APPLYING FOR*
VOTER REGISTRATION PRECINCT*
APPLICANT INFORMATION
Name*

First NameLast NameSuffix
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CURRENT EMPLOYMENT INFORMATION
OCCUPATION*
EMPLOYER*
EDUCATION*
CONTACT INFORMATION
HOME OR MOBILE PHONE NUMBER*
Format: (000) 000-0000.
WORK PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL ADDRESS*
example@example.com
PLEASE LIST ANY STATE, MUNICIPAL OR COUNTY BOARDS, AGENCIES,COMMISSIONS, OR AUTHORITY WHICH YOU ARE CURRENTLY SEATED ON AND THE DATE YOUR TERM EXPIRES.
YesNo
IF YES, PLEASE EXPLAIN.*
(1) BY INITIALING HERE * , I CERTIFY THAT I AM NOT REGISTERED TO VOTE IN ANY OTHER STATE OR IN ANY COUNTY IN THE STATE OF SOUTH CAROLINA OTHER THAN COLLETON COUNTY.
(2) BY INITIALING HERE * , I CERTIFY THAT I AM NOT RECEIVING THE SPECIAL RESIDENTIAL ASSESSMENT ON ANY PROPERTY IN ANY COUNTY OTHER THAN COLLETON COUNTY.
(3) BY INITIALING HERE * , I CERTIFY THAT I AM A RESIDENT OF COLLETON COUNTY.
(4) BY INITIALING HERE * , I CERTIFY THAT AS A VOTING MEMBER OF ANY COLLETON COUNTY BOARD OR COMMISSION, I AGREE TO DISQUALIFY MYSELF FROM VOTING ON ANY ISSUE(S) WHICH MAY ARISE AND IN WHICH A CONFLICT OF INTEREST UNDER SC LAW EXISTS. [CONFLICT OF INTEREST STATEMENT]
I ALSO CERTIFY THAT ALL RESPONSES RECORDED HEREIN ARE TRUE, COMPLETE, AND ACCURATE REPRESENTATIONS OF FACT.
SIGNATURE*

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Once completed, attach a brief resume below. All applications submitted will go to the Clerk to Council, County Council of Colleton, PO Box 157, Walterboro, SC 29488.

Applications without a brief resume’ cannot be considered. All information contained on this application is subject to public disclosure.
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CURRENT DATE*

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APPLICANT INFORMATION

CURRENT EMPLOYMENT INFORMATION

CONTACT INFORMATION