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APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE
Board, Commission t"Committee to which you are seeking appointment:
Applicant Name and General Information
First MI Last
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Home Street Address
Ci Sta e Zip
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dm
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Home phone Work phone Cell phone
E-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? Yeseo
Are you a citizen of the United States? ; No
Are you a City resident? V�s No
If so,how long "" ,, —
Do you own/manage a business in the City? Ye. No
� field? Yes No
Do you hold any professional licenses,registrations or certificates in any
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:
jrk or Professional Experience- List most recent experience first.or attach a resume
Employer Title From(M[Y) To(M/Y)
Brief job description
Employer Title From(M/Y) To(M/Y)
Briefjob description
Employer Title From(M/Y) To
Briefjob description
Eduyation -List most recent experience first
Yes No
Institution/Location Degree earned/Maj or area of study iraduated?
Yes No
Institution/Location Degree earned/Major 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 41— -11
Organization/Location Group's purpose/objective #of members
_D.gif.f description of your participation:Mxwel"z e, C/
V
Organization/Location Group's purpose/objective H of members
Brief description of your participation:_
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Questions
Why are you interested in serving on this particular Board or Co Mission?
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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 make regarding your application.
App ant Signature Date
Submit completed forms to: OFFICE OF THE CITY MANAGER
TERESA PIERCE,DEPUTY CITY CLERK
360-417-4630 or tpierce@cityofpa.us 5
City of Port Angeles
321 E. 5"'
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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