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					                                 NORTH CAROLINA GENERAL ASSEMBLY
Label and staple
wallet-size color
                                    HOUSE OF REPRESENTATIVES
     photo
   to corner                     2012 APPLICATION FOR PAGE APPOINTMENT


                                                                              DATE         / /
RECOMMENDED BY REPRESENTATIVE (Print)
               (Representative’s Signature)
APPLICANT INFORMATION
NAME                                                                          DATE OF BIRTH              / /
                    (First          (MI)                  (Last)

PREFERRED CALL NAME                                                                AGE                       SEX           (M/F)
MAILING ADDRESS
                                              (Street)                                   (City, State)                     (Zip)
COUNTY                                                         SOCIAL SECURITY NUMBER             -      -
TELEPHONE       (    )       -                   E-MAIL (optional)
WEEK AVAILABLE* 1 ST CHOICE:
                     2ND CHOICE
*Weeks begin each Monday the General Assembly is in session starting May 21, 2012.
HAVE YOU EVER SERVED AS A HOUSE PAGE? Y            N      SENATE PAGE ? Y     N          WHEN?           / /
CURRENT SCHOOL
GRADE          INTERESTS/SCHOOL ACTIVITIES


LOCAL NEWSPAPER AND ADDRESS
PARENT/GUARDIAN INFORMATION
FATHER’S NAME
OCCUPATION                                                           BUS. #    (     )     -             CELL #    (   )    -
MOTHER’S NAME
OCCUPATION                                                           BUS. #    (     )     -             CELL #    (   )    -
EMERGENCY CONTACT                                                                  TELEPHONE # (               )   -
SIGNATURE OF CUSTODIAL PARENT OR GUARDIAN

    I give my consent for my child’s photograph to be submitted to the local newspaper listed above along with a press
     release.
    I give my consent for photographs taken of my child while serving as a House Page to be used for House Page Program
     promotional materials and on the House Page Program website.
    I do not give my consent for my child’s photograph to be used for any prupose other than for the submission of this
     application.
                           ***RETURN THE ORIGINAL APPLICATION TO YOUR REPRESENTATIVE.***
           THE NORTH CAROLINA GENERAL ASSEMBLY, 16 W. JONES STREET, RALEIGH, NORTH CAROLINA 27601-1096

For Office Use Only
              Received________________Appointment Date_________________Appointment Letter Sent ______________

				
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posted:10/1/2012
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