HomeMy WebLinkAboutShargel Application 03/02/2015|
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PPRTANGELEI 2 2015
WASH / wGrow' U. S. A.
APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee tw which you are seeking appointment:
Applicant Name and General Information
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First MI Last
Horne Street Address
City State Zip
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Home phone Work phone Cell phone
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E-mail address L/
Date oJBirth (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal
history check mensure compliance with Port Angeles Municipal Code%.Z6.020)
Certification and Location Information (circle one)
Are you employed hy the City of Port Angeles? Yee ( �o/
Are you u citizen vf the United States? /^/ov/ No
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Are you uRegjstermd Voter? (�eo) No
Are you u City resident? (,Yes) No
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Do you ""on/ O r
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City? Yes ._ov'\
Do you hold any professional licenses,registrations o,00rtifiomooin any fioldY Yes '-o_'/~\
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If so, please list:
Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so,please
explain: N 0 1V C
Work or Professional Experience- List most recent experience first,or attach a resume
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Employer Title From(M/Y) To(M/Y)
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Brief job description
Employer Title From(M/Y) To(M/Y)
Brief job description
Employer Title From(M/Y) To(M/Y)
Brief job description
Education - List most recent experience first
),)"A UN! /-A Ay Yes No
Institution/Location Degree earned/Major area of study Graduated?
L�" � -�✓� 1 /S�? Yes �N_Q
Institution/Location Degree earned/Major area of study Graduated?
V i r -�- tJf�- >R. �> ��J ✓ ��/S Tc C7 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
Orga nization/Location Group's purpose/objective #of members
Brief description of your participation: C c i C r /ij1 M 2 6( C u/j �e CvI/l�if 1771 'E� �J JG f l J'f W
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Organization/Location Group's propose/objective #of members
Brief description of your participation:
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Questions
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Why are you interested in serving oothis �Bm�mCmmo �o ?
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V -hat your background m experience do you think would help you in serving ou this Board?
What is your understanding of the responsibilities of this particular Board ooCommission?
Please feel free to add any additional comments you wish to make regarding your application.
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Applicant Signat4e Date
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Submit completed forms to: OFFICE mn THE CITY CLERK
JENNIFER VDNEKLmSom,CITY CLERK
360-417-4634orjvcueklu@oi1ynfoo.ua
City of Port Angeles
321 E. 5"'Street
PO Box ]l50
Port Angeles,\YA 98362
In 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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