HomeMy WebLinkAboutUtz Application 09/04/2015 ® P--QR-T G-E N LES
s W A S H I N G T O N, U. S. A.
APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committe to which you are seeking appointment:
Applicant Name and General Information
First MI Last
Home Street Address
City State Zip
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Home Lhone 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 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
Are you a citizen of the United States? YC No
Are you a Registered Voter? Yeses 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? Yew No
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If so,please list: J/ � Irby C
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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
Employer T tle From(M/Y) To(M/Y)
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Briefj bdescription
Employer Title From(M/Y) To(M/Y)
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Institution/Location Degree earned/Major area of study Gra thiatZa?
h�stitution/Location (J Degree earned/Major area of udy Graduated? L �!
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Institution/Location Degree carne /Major area of study Graduated? O"
Charitable, Social and Civic Activities and Memberships- Lis, major activities you have participated in
duri g the-last five years
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Organization/Locatioh GroupVspurpose/objectiv6 U of members
Brief description of your participation: e-1 V,\
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Organization/Location Group's purpose/objective #of members
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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 experience do you think would help you in serving on this Board?
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What is your understanding of the responsibilities of this particular Board or Commission?
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Please feel free to add any additional comments you wish to make regarding your application.
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Applicant Signature Date
Submit completed forms to: OFFFCE of THE CITY CLERK
JENN'IF'ER VENEKLASEN,CITY CLERK
360-417-4634 or jvenekla @cityofpa.us
City of Port Angeles
321 E. 5°i 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.
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