HomeMy WebLinkAboutApplication 1/5/2017 (2)D
I crrY (;F PORT ANGELES
CITY CLEFIK
EGEIVE
JAN 5 2017I}ORTANGBLES
AppLrcATroN ron ArponuMENTTo BolRD, coltltmsrox oR coMMrrrEE
Boerd, Commission or Committee which you are seekingL)r11 d VrSd
Applicent Nrme ead Generd Informetion
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Filst ks1llt,t €$& sl
IIoDe SEeit Addr€ss
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City Statc
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E-mail addrcss
D!& of Birtt (to bc coDpleted oDly by rpplicEtrtr for public Srfety Advtrory Boerd for purpeces of crhltr.l
history check to emure coEplir[c€ with Port Aryeler Mudcipd Code 2r.6.020)
Cert'fication and Locetion Informrtion (circtc one)
AtD yDu c@loycd by thr City of Pott ADgEtcs?
Ar! ,,ou I sitiz.a of tb Udtrd Starrs?
Ar" ,,qr a RrgirsEd vot€r'?
Arc you a City rcsiicaP
Do pu hold my pmftssiooal lic€osos, rrgistntio[s or certificates in any 6eld?
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No
No
No
No
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Do 1ou own/managc a iu thc Citfn
Yes
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Are you
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auzre of any cmflict of itcrcst uihich mighr arise
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by your scrvicc on a City Board or Conmissiod If so, plcae
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Work or hfessiond Experienoe - Lisr oost r€c€nt €xperi€dc€ first, or strach a rpsume
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Bricfjob descriptioa
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Briefjob description
EdUCedOU - Ust oost rcc€ol cxpqicoc€ 6rst
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Degrec eamod/Iv1ajor area of surdy
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IDsdnrtioD/I-ocation Dcgrcc carned,tv{ajor area of study Graduatcd?
Y No
Instiu.rtioo/Location Degree earocdrlvlajor arca ofsurdy Graduarcd?
Chrrfteblc, Socid end Civlc Activifies eud Memberships - List mnjor activitics you bave panisipcrod i!
driug the last five ycars
all EL-<.O^ofl^. t c +
Orgldzedoollocad,oE
Bdcf dcecripim of yoru prrticipatiou
# ofmenbers
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Bricf dacrbtio of yqE pdtioip.tiou iloand, [0n^6*
Grorp's pwposcr'objective # of @Dbcls
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Gmup's pr:rpose/objectivc
Questions
Why are you interested in serving on this particular Board or Cotnrnission'.)
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tn our background expeflencc do 1'ou thi d irel vou ln s gon his l]oard'.)
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whar rur understandi ng
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Please feel free to add any additional cornrnenls you rrish ro make re!6rding )'orrr applicalion.
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Applicant S Dalc
Submit completed forms to:Ol FlcE oFT E Ct rt Cl.r.:Rr,i
JE\\tFF.R vE\[lir--\sr.]\. Crr\ Cr,t:Rti
360-4 I 7-,1634 or jvenella?cit1 oljra.us
CilY of Port Angeles
f2l E. 56 st.""r
P() Box I150
Pon Angeles. WA 9836:
ln compliance wirh the Americans with Disabilities Act, ifyou net'd sp€cial accorrlrodations because of a physical
limitation. pleese coniact thc CiO Manager's OfIice at 417.4500 so appropriate trrangenrents cao be made.
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