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APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
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Applicant Name and General :Information
First MI Last
Home Street Address _ --
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C."ity State Zip
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Ho -phone --&�Qrk phone Cell phone
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E-mail address
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Gate 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 Part Angeles? Yes
Are you a citizen of"the United States? � No
Are you a City resident? (rjes No
If so,how long
Do you own/manage a business in the City's Ye No
Igo you hold any professional licenses,registrations or certificates in ally field? Yes es
If so.please last:,, _ ..._...._... __,
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Are you aware of any conflict of interest which inight arise by your service on a City Board or Commission? If so,please
explain:
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Work Experience - List most recent experience first,or attach a resume
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Employer Title From(M To(MfY)
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.Brief.job description
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Eni oyer it From(M/Y) To(M/Y)
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Bricfjob description
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Employer Title U From(Mly) To(M/Y)
Brief.job description
Education - List rnost recent experience first
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in—stittition/iL—ocation 0 Degree earnedMkjor area of study Graduated?
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Institution/Loc ion Degree earned/Major area of study —GQau`at —? —
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
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6rganization/Location Groups purpose/objective 4 of members
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Brief description of your participation: ?>W'rA fA ort-b
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Organization/Locatiou Group's purpose/objective 9 of members
Brief description Of Your participation; _ �e
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Questions
Why are you interested in serving on this particular Board or Commission?
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What in your background or expe.rience do you think wot)ld help you as serviV on this Board?
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What is your understanding of -lie responsibilities of this Particular Board or CoTission?
Please feel free to add any additional comments,you wish to make regarding your application.
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Submit conipleted forms to: OFFICE OF THE CITY MANAGER
TERESA PIERCEJ)EPUTY CITY CLERK
360-4174630 or tpierce@cityofpa.LIS
City of Port Angeles
321 E. 5"' Street
PO Box 1150
Port Angeles, WA 98362
In compliance with the Americans with Disabilities Act, if you need special accommodations because ol'a physical
limitation,please contact the City Manager's Office at 417.4500 so appropriate arrangements can be made.
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