HomeMy WebLinkAboutApplication Baliban 10/31/2014 [ CCOMC
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APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment.,
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Applicant Name and General Information
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First MI Last
Home Street Address
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City State Zip _
Home phone Work phone Cell phone
E-mail address
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Date of Birth (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal
history check to ensure compliance with Port Angeles Municipal Code 2.26.020)
Certification and Location Information (circle one)
Are you employed by the City of Port Angeles? Yes
Are you a citizen of the United States? YOs No
Are you a Registered Voter? Yfg No
Are you a City resident? No
If so, how long_ 9_'l 6A f_ S
Do you own/manage a business in the City? Yes M&
Do you hold any professional licenses, registrations or certificates in any field? Yes Imo°
If so, please list:__________._
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Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so, please
explain:
----—-----
Work or Professional Experience- List most recent experience first,or attach a resume
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Employer Title From(MN) To (M/Y)
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Brief job description
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Employer Title From(MN) To (MN)
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Brief job description
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Employer Title From(MN) To (MN)
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Brief job description
Education - List most recent experience first
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Institution/Location Degree earned/Major area of study Graduated?
Yes No
Institution/Location Degree earned/Major area of study Graduated?
----Yes No
Institution/Location Degree earned/Major area of study Graduated?
Charitable, Social and Civic Activities and Memberships - List major activities you have participated in
during the last five years
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rganization/Location Group's purpose/objective #of members
Brief description of your participation:-C 0 0 5 T e U cT 10 IQ P fe-0�" I- C_-C W 15: � K �N P C'R'�VJ S
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Organization/Location Group's purpose/objective #of members
Brief description of your participation:_M I b F1�Z, tV/? FOR-' Gi 0 0 7-0 0 TEAM.
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Questions
Why are you interested iD serving 0D this particular Board or Commission?
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What in your background or experience do you think would help you in serving on this Board?
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What is your understanding of the responsibilities of this particular Board or[|0OOOOi8siOO?
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Please feel free to add any additional comments you wish to make regarding your application.
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plicant Signature Date
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Submit completed forms to: OFFICE OF THE CITY MANAGER
TERESA P|ERCE' DEPUTY CITY CLERK
360'417`4830 Ur1pi80C8@Ci[V0fD8.US
City 0f Port Angeles
321 E. 5 1h Street
PO Box 115O
Port Angeles, VV/\ 98362
|n compliance with the Americans with Disabilities Act, if you need special accommodations because ofaphysical
limitation, please contact the City Manager's Office at 417.4500 so appropriate arrangements can be made.
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