HomeMy WebLinkAboutApplication 01/27/2014 PQRTXLGELE1 YN 27 2014
,a W A S H I N G T O N, U. S. A. E,,"S
�„T YF 1 F h,
APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
Applicant Name and General Information
,,. . ...
First ?tt p-f--trk MI Last
Home Street Address t
City State Zip
Home phone Work phone Cell phone
E-mail address
'° -0
Date of Bi li (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 (No
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 __
Do you own/manage a business in the City? Yes No
Do you hold any professional licenses,registrations or certificates in any field'? es 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
i - UvAv 15
E� p 10 Vy e Ir / Title From(M/Y) To(M/Y)
ke[o
Brief job d script i(m
O/ all ? -7
-0-- te
�Ie (M,—Y)
Employer t From(M/Y) J To
Brief job description
Employer /Utifle From(M/ ) To(WY)
Brief job description
Education - List most recent experience first
R '" 2 - - V'f
Yes
No
Institution/Location 4rceeamed/Major
area of study ra ated?
el
es) No
Institution/Location Degree earned/Major area of study Gra6ated?
N bkl�t�-K-/ kwe�,`Tljl earned/Major No
Y,�e
Ye'
Institution/Location Degree earned/Major area of study Ye'
uateW
/ FS�a
Charitable, Social and Civic Activities and Memberships - List major activities you have participated in
during the last five years
,...__... ,=zz..
�e
rat
Organization/Location Group's purpose/o ctive of members
Brief description of your participation:
A�0 aniz n/ ocation Group s purpose/objective #of members
a rml?
iza i
Brief description oyfour participation:
L
2
Questions
Why are ou nterested in serving on this particular Board or Commission?
(2 2�
LY) I
G 0/�
-)
What in your back ound or experience day think wouldp�l you in serving on this Bob'd
�e
(5 �J D X>
What is your understandi of the responsibilities of this particular Board or Commission?
Lit?
Please feel free to add any additional comments you wish to make regarding your application.
Ile
7�
Ap i ant Signature D
Submit completed forms to: OFFICE OF THE CITY CLERK
JANESSA HURD,CITY CLERK
360-417-4634 orjhurd(&
,cityofpa.us
City of Port Angeles
321 E. 5`h 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.
3