HomeMy WebLinkAboutSmith Application 12/18/2017 Q��'TANGELES
W A S H I N G T O N, U. S. A.
APPLICATION FOR APPOINTMENT TO BOARD,,COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
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Applicant:flume and General Information
First M1 St
5
Horne Street Address
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" y � este Zip
27
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 Port Angeles Municipal Code 2.26.020)
Certification and Location Information (circle one)
Are you employed by the City of Part Angeles? Yes Q<P
Are you a citizen of the united States: No
Are you a Registercd.Votee? @^��°�r es,,k No
Are you a City resident'? "���Yes,, No
If so,how longi µ
Irpo you own/manage a business in the City? Yes P
Ido you hold any professional licenses,registrations or certificates in any field? e s leo
If so,please list; :`
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Are you aware of any conflict of interest which nrigJit arise by your service on a City Board or Coinniiision? If so,please
explain:
Work or Professional Experience-List most recent experience first,or attach a resurne
41 ........... 7
Employer Title From(M/Y) To(M/Y)
iiief job description
nployer Title FroFrom(M/Y) To(WY)
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—Bric�J;bdfe'!ription
Employer Title From(M/Y) TO(M/Y)
giiefjob
Education-List mast recent experience first
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Institution/Location Degree earncdaMajor area ofstudy Graduated?
Yes Plea
Institution/Location Degree earned/Major area of study Graduated?
Yes No
Degree canted/Major area of'study Graduated?
Charitable, Social and Civic Activities and Memberships-List major activities you haNT participated in
during the last five years
Orgmuzittion/Location Group's purpose/objective #o if nnree n ibb
Brief description of your participation:_. 4"
zation/LA)cation 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 Beard ora Commission?
y y p y n this Board:
What in our background or experience do you think would het you in se bn o
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at is your understanding of the responsibilities of this particular Board or Commission?
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Please feel free to add any additional comments you wish to make regarding your application.
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.Applicant Signature Date
Submit completed forms to: OFFICE E car THE CITY CLERK
JENNIFER R ENI+LASEN,CITY CLERK
360-417-4634 orjvenekla@,cityo1`pa.us
City of Port.Angeles
321 l3. 5,h Street
Fort 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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