HomeMy WebLinkAboutApplication Malane 02/18/2016 CC� C��MC�
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F8 18 2016
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cn Y of PORT ANGELES APR i 5 201
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PORT ANGELES crl-r or- NJ'I ANGELES
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W A S H I N G I- ON, U. S. A.
APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTER
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Board,Commission or Committee to which you are Seeking appoint teut:
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Applicant Name and Ceneral Information
First Last
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Hoare Street Address(
o,�-� WA
City state Zip
(L('0)* 61,4)
I lone phone Work phone Cell phone
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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 No
Are you a citizen of the United States? `1'es No
Are you a Registered Voter? Yes No
Are you a City resident? G;S) No
If so,how
Do you own/manage a business in the City? G No
Do you hold any professional licenses,registrations or certificates in any field? Yes No
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:
Work or Professional{{Experience - List most recent experience firms or attach a resume
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Employer Title �J—F-rollio /Y) To(MA
Brief job description
Employee Title 1)-0111(M/Y) To(NIN)
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Brief job de scription
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Fmployer Title F rolil(NI/Y) To(M/Y)
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Brief job description
Education -List most recent experience first
rk 6 No
I list it tit ion/Locat iatI -bearec earned/Major area of y Graduated'
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IrlStitUtion/Location Degree earned/Major area of study Graduated?
Yes No
Institution/Location Degree earned/MaJorarea of study Graduated?
Charitable,Social and Civic Activities and Memberships - List major activities you have participated in
dill-irIg the last five years
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Organization cation Group's purpose/objective
of members
Brief description of your participation:_ 1 -_-Ic j
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Organization/Location Group's ptjrpose/obJ eel ive 11 of members
Brief description Of'your participation:
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Questions
Why are you interested in serving oil this particular Board or Commission'?
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W]1ajt in 1otu-backtT)'0und Q� experience do you think would help(y ou in sewn ie on this Board'?�
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What is your understanding of the yespotnsibilIIies of this particular 3oard of Con mission?
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Please feel free to add any additional comments you wish to make regarding your application.
Applicant Si_iatm* Date
Submit completed forms to: Orrtcl,or'rut:Crn Ct,elm
360-417-4634 or-jvenekla!a;cityofpa.us
City oi'Port Angeles
321 F. 5"'Street
PO Box 1 150
Port Angeles, VIA 98362
Ili compliance with the Americans with Disabilities Act,if you need special accommodations because of physical
limitation,please contact the City Manager's Office at 417.4500 so appropriate arrangements can be made.
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