HomeMy WebLinkAboutCampbell Application 03/25/2015 IVMAR 2 5 2015
____j
PCITY F PO T NGELES�
WASHINGTON. U. S. A.
APPLICATION FOR APPOINTMENT TO BOARDS COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
Applicant Name and General Information
First
r� MI Last
Home Street Address /
City :j State Zip
Home phone Work phone Cell phone
�O'��' �� f-�. - _� 6�r�Q✓8 � m 4-I�rll'f
E-mail address
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 (50
Are you a citizen of the United States? (_Yes No
Are you a Registered Voter? Yes No
Are you a City resident? Yes No
If so,how long
i"
Do you own/manage a business in the City? Yes No
Do you hold any professional licenses,registrations or certificates in any field? Yes No
If so,please list:
1
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
In Ar,7 I,e�ly Z? -�,Vulw I
Employer Title From(MA) To(MN)
re
/Zefjob ks�ption
i
?
Employer itle From(M/Y) To(M/Y)
f—-Etfk 0 A"p
1` /' --S
Brief job description
J--
C err
6&2
Employer V Title From(M/Y) To(MN)
w I
erkv,-�
4
Z f-A�7 i0le CtIlo A/,,Q C11
Brief job description
-may C V
Education -List most recent experience first
-4—
0 11 P/(72 e,r VAe No
Institution/Loc'ation Degree earned/Major area of stud/ Graduated?
r/ J
'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 --
—5
j2�Elfil 145-In
Organization/Locatron I V
Group's purpose/objective #of members
Brief description of your participation:. f s V
Az
Organization/Location Group's purpoee/objective #of members
Brief description of your participation: 0 g `«? w Jr e-
de J
ced?, r
V
2
Questions
Why are you interested in serving on this particular Board or Commission?
f°e d,3 y %�:� s� t'/-C4 d7s ti e
What in your background or experience do you think would help you in serving on this Board?
&_a, y gg .fir Y 1� �"} ,�-+ ).
zz) , i Jf a �. l%rf� d 6 1 5-"f/ -
What is your understanding of the responsibilities of this particular Board or Commission?
Please feel free to add any additional connnents you wish to make regarding your application.
m
r e
ti
Applicant Signature Date
Submit completed forms to: OFFICE of THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 orjvenekla@cityofpa.us
City of Port Angeles
321 E. 5th Street
PO Box 1150
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.
3