HomeMy WebLinkAboutBruch Application 1/28/2015 , N 2 8 2015
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CITY OF PORT"ANGELES
W A S H I N G T O N,Via U, S. A. CITY CLERK
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APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board,Commission or Committee to which you are seeking appointment:
Applicant Name and General Information
First ml Last
Home Street Address
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City state lip
t-lomc phone � Work phone Cell phone
1 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)
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Certification And Location Information (circle one)
Are you employed by the City of fort Angeles? Yes t
Are you a citizen ofthe United States? No
Are you a Registered Voter? No
Are you a City resident? Yes
If so,how long---- -- -
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Do you own/manage a business in(lie City? es No
Do you hold any professional licenses,registrations or certificates in any field'? Yes No
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11'Sol. _lease list:
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Are you aware of any conflict of interest which might arise by your service on it City Board or Commission? 11'so,please
explain:
Work or Professional Experience- List most recent experience first,or attach a IVA1111C
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F1•0111(M/Y) To(M/Y)
Briclj( eseription
es, All
Title To(M/Y)
From(M/Y)
BriefJob description
1"Imployer 'Iltle From(M/Y) To(M/Y)
Briet'job description
Education - IJSI most I-Ceem expelicue 111'st
No as
Institution/Location Degree earned/Major area of'studyj Graduated?
---
Yes No
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Institution/Location Degree earned/Major area of study Oraduated?
Yes No
Institution/Location Degree earned/Major area of study ("Icaduated?
Charitable, Social and Civic Activities and Memberships- List major activities you have participated in
during the last five years
Orgmlizatioll/Loceatioll Group's purpose/objective 11 of members
Brief description ofyour participation:_
Organization/Location Group's jIUl'POSe/0b ective 11 ofinembers
Brief description or your participation;",_
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Questions
Why are yota interested�in serving on this Particular Board or Conumssion?
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What in yotir background or experience do you think would help you in serving on this Board?
What is your understanding oi'the responsibilities of this particular Board or Commission?
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Please feel free to add any additional comments you wish to make regarding your application.
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Ap sire Date
Submit completed forms to: Orrice OF THE,CITY CLERK
JENNIFER VGNEKLASI N,CITY CLERK
360-417-4434 or_jvenekla @)cityofpa.us
City of Part Angeles
321 E'. 5"'Street
PO Box i ISO
Port Angeles, WA 98362
In compliance with the Americans with Disabilities Act,if you treed special accommodations because ofa physical
limitation,please contact the City Manager's 0111ce at 417.4500 so appropriate arrangements can be made.
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