Mayor's Commission on Aging Membership Application Form

Phone Number

Business Email

Business Phone Number

How will your experience/education/expertise relate to the work you do on the VBMCOA:

In your opinion, what projects or programs could the VBCOA do to help the growing senior population of Virginia?

How would you like to be involved in those projects?

On which of the following committee(s) would you prefer to serve? Please indicate how you could assist on chosen committee(s).

Transportation

Housing

Health & Safety

Legal/Legislative

Community Concerns

Public Relations

Emergency Preparedness

Have you ever attended a VBMCOA meeting as a Guest? If no, it is encouraged that you attend at least one meeting as a Guest.

Yes

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.