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HomeMy WebLinkAboutApplication 3/20/2014 (5) PQR TAN EEti'. ,' MAR W A S H I N G T O N, U. S. A. Es � APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE Board, Commission or Committee to which you are seeking appointment: Applicant Name and General Information L.. First MI Last t & Home Street Address City State zip Home phone Work phone Cell phone E-mail address Date of Birth (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal history cheek 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 Nom Are you a citizen of the United States? C Ye No Are you a City resident? Yes (DO If so,how Do you own/manage a business in the City? (Yes , No Do you hold any professional licenses,registrations or certificates ill any field? Yes No If so,pleaselist: ."I/ d` -- -- 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 Experience - List most recent experience first, or attach a resume Employer Title From(MJY) To(M/Y) -e.vIEPM I,aj R 1 01 fil ldffA I I A , /)?I L Brief job description lkwl ec-6LPff� A--r (c P-r ive�6,wl oe Employer Title From (M/Y) To(M[Y) 6 RT oi� ttftr_4i_q­Y o6e.CAJW�3' -Ik-LgE K?6-564,�-T' Brief job description L- eorr- 31 IT"I 4 Employer Title' From(K41Y) To(M/Y) - lee,�4a,)4- Brief job description Education - List most recent experience first Institution/Location De�n-ee earned/Major area of study Graduated? No 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 Organ ization/Location Group's purpose/objective #of members Brief description of your participation: Organization/Location Group's purpose/objective It of members Brief description of your participation:_ 2 , Questions Why are you io1enahx} in serving on this particular Board or Commission? What ill yourbackground or experience do you think would help you in serving oil this Board? What ia your understanding of the responsibilities of this particular Board or Commission? Please feel free to add any additional comments you wish (omake regarding your application. 2o t Applicant Sigi 4ure Date Submit completed forms to: OFFICE OyTHE CITY MANAGER 1[D1lESA PIERCE,DEPUTY CITY CLERK 360-417-4630 or(pierce@uityofha.uo City of Port Angeles 321 |2. 5 m Street PO Box ll5O Port Angeles, VV& 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 call be made.