HomeMy WebLinkAboutApplication Aubin 12/03/2014 I�
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APPLICATION FOR APPOINTMENT TO BOARD,COMMISSION OR COMMITTEE
Board,Commission or Committee to which you are seeping appointment:
Applicant Name and General Information
First MI Last
Home Street Address
City State Zip
366 3GO g2-06
Hoene phone Work phone Cell phone
E-inaff address
Date of Birth (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal
histom 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 No
Are you a citizen of the United States? es No
Are you a Registered Voter? No
Are you a City resident? es No
If so,how long 7 l�S+ � �✓S
Do you own/nuanage a business in the City? Yes
Do you hold any professional licenses,registrations or certificates in airy field? <te� No
If so,please list: Pkil S+c«2 s l
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Are you aware of any conflict of interest which might arise by your service on a City Board or Couurrission? If so,please
explain:
Work or Professional Experience-List most recent experience first,or attach a resume
Employer Title From(M[Y) To(M/Y)
e ir' �l v 1 .(�� O✓� \�(e{� t�w�S 1�t 1 t i.(�
Brie job description (�
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Employer Title From(M/Y) To(MJY)
Brief job description
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Employer Title from(M/Y) To(Mn')
Brief job description
Education-List most recent experience first
G.ZGtve CdIt, No
Institution/Location Degree carned/Major area of study racquatcd?
es 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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Organizatiom'Location (:croup's purpose/objective #of members
Brief description of your participation:
Organization/Location Group's purpose/objective #ofinembers ��-
Brief description of your participation:
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Questions
Why are you interested in serving on 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?
What is your understanding of the responsibilities of this particular Board or Commission?
Please feel free to add any additional comments you wish to make regarding your application.
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Applicant Stgnantre �y�/� �
Date
Submit completed forms to; OFFK.E OF TIIE CITY CLERK
JENNITER VENIIKLASEN,CITY CLERK
360-417-4634 or jvenekla aicityofpa.us
City of Port Angeles
321 E. 5`t'Street
PO Box 1 150
Port Angeles,WA 98362
Iu compliance with the Americans with Disabilities Act,if you need special accommodations because of a physical
limitation,please contact the City Manager's Office at 417,4500 so appropriate arrangements can be made.
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