HomeMy WebLinkAboutMalane Application 04/15/2015 APR 5 2015 J-
PORT ANGELES POR F ANGELES
CITY CLERK
WASH INGTON, U. S. A.
APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMr\,IITTEE
Board, Commission or Committee to which you are seeking appoint ylent:
Applicant Name and General Information
First -3 MI Last
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[ionic Street Address
flo-'r+ A)15ce' WA ISIS 6 d�
City State Zip
6 1,- 0) 01 0( /
Home phone Work phone Cell phone
E-mail address J
Date of Birth (to be completed only by applicants for Public Safety Advisor), 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 co
Are you a citizen of the United States? Yes '[No
Are You a Registered Voter? Yes No
Are You a City resident? G:1) No
If so,how long___
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Do you own/manage a business in the City?
0Y e No
Do you hold any professional licenses,registrations or certificates in any field? Yes No
If so,please list:
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� Are you aware of any conflict of interest which might arise byI"v,service ona City Board m Commission? |fmplease
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'| Wurkoi-ProYeou|oou) Experience- Lim most recent cx;�,i onoo first.n,xuod,
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Employer Title {J From(N lo(mr/)
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Brief.job description
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Employer(S-PC Title From(M/Y) To(M/Y)
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Brief.job description
Employer Title From(M/Y) To(M/Y)
Briefjob description
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Education ' List most recent experience ficu
-ode Ab" 6 ' 'A , 6-w-1) lu ..... Y�e� NL(
'IStitUtion/Location Degree earned/Major area ofstudy Graduated?
Yes NO
� Degree ' '
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Charitable,Social and Civic Activities and Memberships - List major activities you have participated in
dodug the last five years
Organization/Location GrOLIJ)'S purpose/ob of members
jective
Brief description ol'ynv,yonici»ation
Organ ization/Location Group's purpose/obliective 11 of members
Brief description o[yomr pail iciyxhou:
Questions
Why are you interested in serving on this particular Board or Commission?
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W11t m our back-MUnd Q experience do you thi�ik'WOL�ld helpLyou in servi�g on this Board?
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What is your understanding of the responsibilities of this particular 3oard or)Crn7 mission? Q
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Please feel free to add any additional comments you wish to make regarding your application.
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Applicant Si-iatur Date
Submit completed forms to: OFFICE OF THE-CITY CLF RK
JE NIFUR VENEKLASEN,CITY CLERK
360-417-4634 or jvenekla((,cityofpa.us
City of Port Angeles
321 E. 5°i Street
PO Box 1 150
Port Angeles, WA 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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