HomeMy WebLinkAboutApplication 2/15/2017 (3) l l ,u v YY''jj
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WASH INGTON, U. S. A.
APPLICATION FOR APPOINTMENT Tl ENT TO BOARD, COMMISSION OR COMMITTEE
� y seem appointment:
Board, �°
,omrton or Committee to which on are
Applicant Name and. General Information
First SII Last
I fonte Street Address �M
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City State Zip
florne phone Work phone Cell phone
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E-mail adclre ss
Date of March. (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal r..
history check to ensure compliance with Port Angeles Municipal Code.2.26.020)
Certification and Location Information (circle one)
,re you emplcoyed by the City of port Angeles`? Yes 0'
.arc:,you a citizen of the United States? y es No
Are you a registered Voter? ryYci No
Are you a City resident? `t' No
If so,how
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Do you own/manage a business in the:City'! Yes ?")
Iyo you hold any professional licenses„registrations or certificates in any field':? Yes
If so,please list: ..W .....
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Are you aware of any conflict of interest which might arise by your set-vice on a City,Board or Commission? If so,please
explain:
Work or Professional Experience-List most recent experience first, or attach a restime
er 'Title Front(M/Y) To(M/Y)
Briefjo
Eniplo
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[l�iiejob d4—�i�tlion
Employer Title From(M/Y) 'To(M/"`w")
Brief job description
Education- List most recent experience first
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Institution/Location e ee earnned l faor area of study Graduated?
Intstitution-11.,o—c.it-i-o-n�—' TDe gree ea edJl lafcar an ca�f stud Oraduated?
Yes No
Institution/Location Degree earnedJMajor area of study ---4.`71,raTuated?
Charitable, Social and Civic Activities and Memberships-List major activities you have participated in,
during the last five years t
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Occ,
V111-pose/o J cc Ifiv c #of'I ernt
rgarlizatio, /Locatio Group S p N h,
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Brief description of your participation:,,, /A V IAOiAJ14,PAIIP
Y.
AN-
� anlZation I ation Group's purpoft ve 4, f members
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Brief description of' Poor 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 can this Board"?
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What is your understanding of the responsibilities of this particular Board or Commission'?
f le s�ee1 .re( d it na comments you wish o ma e re�kard =your application.
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pplicant7-7
ignat l.7 ate
Submit completed forms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-4174634 or.pvencklai r cityo laa.us
City of Poet Angeles
321 E. 51h Street
Port Angeles, CdA 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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