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APPLICATION FOR APPOINTMENT TO BOARD9 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
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Home Street Address
City State Zip 7
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Home phone Work phone Cell phone
E-mail address
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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
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Are you a citizen of the United States? (_ No
Are you a Registered Voter? mW - No
Are you a City resident? Ye No
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Do you own/manage a business in the City? Yes 0)
Do you hold any professional licenses,registrations or certificates in any field? Yes �Na
If so,please list:
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Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so,please
explain:
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Work or Professional Experience-List most recent experience first,or attach a resume
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Employer Title From(M/Y) To(M/Y)
Brief j Db description
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Employer Title From(M/Y) To(M/Y)
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Brief job description
Employer Title From(M/Y) To(M/Y)
Brief job description
Education -List most recent experience first
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Institution/Location Degree earned/Major area of study "raduated?
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Institution/Location Degree eaneMajk or area of study duat
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Institution/Location Degree earned/Major area of study u d?
Charitable, Social and Civic Activities and Memberships -List major activities you have participated in
during the last five years
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Organization/Location Group,s purpose/objective of members
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Brief description of your participation: Ile
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Organization/Location Group's purpose/objective A of members
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Brief description of your participation:
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Questions
Why are you interested in serving on this particular Board mCommission? �
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What in your b�alcground or experience A you think would help you in serving on this Board?
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What is d mt di of the responsibilities of t|d particular Board orCoo?n!isakor? ,wg�
Please feel free to add any additional comments you wish to make regarding your application.
Applicant SignAurej Date
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Submit completed forms to: OFFICE OF THE CITY CLERK
JAN E8SA HNRD,CITY CLE RK
960-417-4634orjhun\@cityofha.ua
City nf Port Angeles
321 E. 5 1h Sboo1
PU Box l\50
Port Angeles, W/\ 98362
10 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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