HomeMy WebLinkAboutApplication 2/13/2017 Y.mf a .a
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WASHINGTON, U, S, A. 2017
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
First MI Last
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Home Street Address
City State Zip
Home Flrone Work phone Cell phone
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E-mail address
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Date of Birth (to he 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
Are you a citizen of the U ni ted States? No
Are you a Registered Voter? >efNo
Are you a City resident'? yes
If so,how total;
Do you ownCananal e a business in the City? No
Do you IvId any professional licenses,registrations or certificates in any field? iia
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 Professional Experience - List most recent experience first,or attach a resume
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Employer Title From(M/Y) To(M/Y)
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Brief job description
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Employer Title From(M/Y) TO(M/Y)
Brief job description
Employer Title From(M[Y) To(M/Y)
Brief job description
Education - List most recent experience first
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Institution/Location Degree camed/Major area of study Graduated?
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Institution/Location Degree earned/Majorarea of study Graduated'?
Yes No
Institution/Location Degree earned/Major area of study Graduated?
Charitable, Social and Civic Activities and Memberships - List major actiN,itiesvou have participated in
during the last five years
Organization/Location Group's purpose/objective 4 of members
Brief description of your participation:
Organization/Location Group's purpose/objective #of members
Brief description of your participation:
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Questions
Why are you interested in serving on this particular Board or Commission?
What in your background or experience do you think ould help you in serving on this Board`?
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What is your understanding of the responsibilities of this particular Board or Commission'?
Please feel free to add ariv additional comments you wish to make regarding your application.
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Applicant Signature Date
Submit completed forms to: OFFICE OF` HE CITY CLERK
JENNIFER VFNFKI,ASFN,CITY CI,P,RK,
3)604 1.74634 or*venekla��icityofpa.Lis
City of Port Angeles
321 E. 5"' Street
Port Angeles,WA 98362
In compliance with the Americans with Disabilities Act,if you need special accommodations because of a physical
Innitation,
please contact the City Manager's Office at 417.4500 so appropriate arrangements can be aiade.
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