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APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION SION OR COMMITTEE
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Board, Commission or Committee to Which you are seeking appointment;
Applicant Name and General Information
First M'II Last
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Home Street Address
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City State Zip
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+*Ane-phone ( Werft-phone Cell phone]
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F..,-mail address
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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? Ye No
Are you a City resident? SSS,) No
If so,how
Do you own/ma ge a busines, in the City?c/b l In tel ( i'n Y),
r1 Yes No
Do you hold any profession licenses,regrst7•ations or certificates in`'ay field? Yes No
If so,please list:
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 Experience - List most recent experience first,or attach a resume
Employ6r Title From(M/Y) To(M/Y)
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Brief j 86—de—s�-�ri)tiol(:::)
Employer Title Froin(M/Y) To
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Brief job di tion
0141- 704
Eter'i Title From (M/Y) To(M/Y)
Brief job description
Education - List most recent experience first
uA Y)I Yes o
lnstitutiocat on Degree earned/Major area of study ated?
�Jnstitn&tion/L
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
Organization/Location Group's purpose/objective 9 of members
Brief description of your participation: Yqkwj YA&vih-a- r---;)Y) 2 DV�K
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Organ ization/Location 1 1-/ 1 1 Group's purpose/objective #of members
Brief description Of your participation: A
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Questions
Why are you interested in serving on this particular Board or Cormnission?
Q 402
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What in your background or experience do you think would help you in serving on this Board?
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 snake regarding your application.
Applicant r nature Date
Submit completed forms to: OFFICE OF THE CITY MANAGER
City of Port Angeles
321 E. 5`h 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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