HomeMy WebLinkAboutApplication Graf 02/12/2014 � �
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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
First MI Last
Home Street Address
City 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? (Y ,' No
Are you a Registered Voter? eft No
Are you a City resident? Yes No
If so,how long (r,
Do you own/manage a business in the City? ( 'e5 No
Do you hold any professional licenses,registrations or certificates in any field? Yes No
If so,please list: � ... t,� C�_�1�'`-C � e—
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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
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
(Yes) No
Institution/Location Degree earned/Major area of studyw. u a—te d—?
�Ye§) No
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Institution/Location Degree earned/M;�jor area of study �YVau—ate
No
-Ac Ye
Institution/Location Degree earned/Major area of study Gfiiduated?
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: r.�
Organization/Location Group's purpose/objective #of members
Brief description of your participation: x',
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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 on this Board?
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What 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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AP' nature Date
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Submit completed forms to: OFFICE OF THE CITY MANAGER
TERESA PIERCE,DEPUTY CITY CLERK
360-417-4630 or tpierce@cityofpa.us
City of Port Angeles
321 E. 5h 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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FIREARMS TRAINING
SIGSALIER ACADEMY
101 Hand Gun Orientation—Basic Firearms Safety Course for Handgun Owners—Todd Horn
102 Basic Practical Pistol Skills—Todd Horn
Low Light Pistor Operator—Chris Cava Ila ro
Concealed Carry Pistol—Todd Horn
Close Quarter Pistol Operator
556 Operator Course—Todd Horn
Reflexive Shooting—Scott Herringson
Bullets and Bandages—Kerry Davis
Bullets and Vehicles—Kerry Davis
Executive Protection Operations—Tim Arnold
Civilian Response to Terrorist Attacks—Todd Rassa
Force-On-Force Response to the Active Shooter for the Concerned Citizen—Todd Rassa
Civilian Response to Terrorist Attacks—Force-on-Force—Todd Rassa
Preparation for Social Collapse—Todd Rassa
Advance Social Collapse—Todd Rassa
GUNSITE ACADEMY
Precision Rifle 7—Corry
THE FIREARMS ACADMENY OF SEATTLE, INC
Weeklong Handgun—Marty Hayes
EDUCATION
University of Arizona—Bachelor of Science
License Massage Practitioner-Peninsula College 11-I'lli
Certified in Craniosacral—Milne Institute, Big Sur, CA 1.
Certifiedin Medical Qi Gong—China `t
Certified Nutritional Therapist (now a Nutritional Therapist Practitioner)
LifeStyle Educator—Metagenics Inc. ';b o