HomeMy WebLinkAboutKirsch Application 01/05/2017 •
PQRTAliGELES
It.`�- WASH I N G T O N, U. S. A.
APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE
Board, Co�[mmisssiion/ 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
PML 61 (il/✓�' 1 Fs 4o Z
City 6P State Zip
Home phone 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 No
Are you a citizen of the United States? No
Are you a Registered Voter? No
Are you a City resident? No
If so,how long �'� r ( ® ® //�(�
Do you own/manage a business in the City? Yes No
Do you hold any professional licenses,registrations or certificates in any field? Yes
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:
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)
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Brief job"description
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Employer Title From(M/Y) To(M/Y)
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Brief job descriptionJ
Education -List most recent experience first /
�b4 � �/ I c�1M4 l � e No
In-tit ii/Location II,, Degree eamed/Major area of study P �+ raduated?
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Institution/Loca ion Degree eame ajor area of study Graduated?
Yes No
Institution/Location Degree earned/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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Organization/Location Group's purpose/objective #of members
Brief description of your participation: I/1,C..., C-L t ( y/at
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Organization/Location Group's purpose/objective #of members
Brief description of your participation: V PVd; r
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Questions
Why are you interested in serving on is particular Board or Commission?
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What in your ckground or experience do you t is wouldo&you in serving on t Board? r
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What isnI ; r
etanding of the ret sU ponsibilities of this }cular Board or Commission
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Please eel free to'add any additional comments ou wish to make regarding your pplication.
✓ Or t,tl y
-A
ppi ant Signature Date
Submit Completed forms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 orjvenekla@cityofpa.us
City of Port Angeles
321 E. 5t'Street
PO Box 1150
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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