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APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
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Applicant Name and General Information
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First Ml Last
Home Strut Address
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City State Zip
Home 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 fort 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? No
Are you a Registered Voter? �° Yes,,,, No
Are you a City resident`. Yes 23
If so,how long
Do you own/manage a business in the City? No
N � � any field. � �Yes 110 ... ,
Do you hold any professional licenses registrations or certificates inn ?
� .�.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 Pro, e sional Experience-List most recent experience first,or attach a resume
Employer (M/Y) To(M/Y)
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Employer` Title Fro d(MJY) P To
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Brief j description
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fmpl6ye,r Title Fr(Yrn(M/Y) To(*Yf
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Briefjobr&'ription
Education - List most recent experience first
t//- i�s
No
1A;tinnionLca' tiot7 Degree earned/Nl4jor area of study
Yes rNo 'I
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Institution/Location
Degree earn6d/Major area of study Graduated?
Yes No
Institution/Location Degree eamed/Major area of study Graduated?
Charitable, Social and Civic Activities and Memberships -List major activities you have participated in
during the last five years
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Organi7aiiordLocation Group's purpose/objective #of members
Brief description of your participation:
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Organization/Location ft of members
Brief description of your participation:
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Questions
Why are you interested in serving,on t s 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?
What is your understanding of the responsibilities of this particular Board or Cormnission?
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Please feel free to add any additional onunents you wish to make regarding your a plication.
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Applidant!Sighature D e
Submit completed forms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 or jveneklaCa)cityofpa.us
City of Port Angeles
321 E. 5s"Street
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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