HomeMy WebLinkAboutApplication Utz 02/19/2016 F C E W E
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ORTNGELES
FEB 1 9 2016
Iv A-1 W A S H I N G T O N, U. S. A. � i�� vF- PORT ANGELES
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APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committe 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 �y
I Cit 41+C
State Zip
]-ionic phone4 ` 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 �o
Are you a citizen of the United States? Ye No
Are you a Registered Voter? Yes 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? No
If so,please list: �_1��7
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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: ,
Wot'k 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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Brief' b description `l yam. f} i � r �yti iGFi . ��.,,mac J
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Employer Title Froin(M/Y) To(M/Y)
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Employer Title From(M/Y) To(M/Y)
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Brief job e cry ilntioi
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Educatign - List most recent experience first
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Institution/Location Degree earned Major area of study Gra
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Institution/Location Degree earned/Major area of udy Graduatca
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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/Locatio n Groups purpose/objectiv #of members
Brief description of your participation: _ C
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Organizatio�>/Location Group's purpose/objective tt of members
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Brief escription of, our participation:
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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 Con-nnission?
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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: OFFICE or THE CIT CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 orjvenekla@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 ofa physical
limitation,please contact the City Ylanager°s Office at 417.4500 so appropriate arrangements can be made.
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