HomeMy WebLinkAboutJohnson Application 06/01/2017 P TA1 2017
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APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
Applicant Name and General Information
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first N41 fast
14j)rne Street Address
City State Zip
Monne phone Work phony,. Cell phone
E-mail address
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E ate of Birth (to be completed+array by applicants for Public Safety dvisor):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 fort Angeles'? Yes Q 0
.re you a citizen of the United States? Ce a leo
Are you a Registered Voter`? Yea J No
Are you a City resident`? �s,�' No
If so,how long_...........................
Do you own/manage a business in the City"? Yes
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: ev&
Work or Professional Experience-List most recent experience first,or attach a resume
Employer — Title From(M/Y) To(M/Y)
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
es No
Institution/Location Degree earned/Major area of study fiaiauated?
—Yes No
Institution/Location Degree camed/Major area of study Graduated?
Yes No
Institution/Location Degree carned/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 purposd/objective #of members
Brief description of your participation: 7— 4< 77W
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Organization/Location Group's purpose/objective #of members
Brief description of your participation:
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Questions
Why are you interested in serving oar this particular Board or Commission?
y ground orexperience do your p i � . g his Board"?
"khat in our back think would het you in serving on t
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!hat,is your understanding of the responsibilities of this particular Board or Commission?
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Please feel tree to add any additional comments you wish to snake regarding your application.
Applicant i Date
Submit completed forms to: OFFICE OF THE CITY CLERK
JENNIFER V NEKLASEN,CITY CLERK
3604174634 or jvenekla( cit ofpa.us
City of Port Angeles
321 E. 51'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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