HomeMy WebLinkAboutApplication 01/01/2011 PORTNLGELES
WASHINGTON, U, S. A
Application for Appointment to a Board, Commission, or Committee
Bo rd, Commission, o Committee to which you are seeking appointment:
Al l �: ON/
Berard or Commission F ll Name
A plicant dame and General Information
First MI Last
aa
7op Street Ad,..ess w.
City State Zip Code
Rome phone number Work phone number
f ..
E-Mail Address: 6.�° �� ��.. "� � C_ �., �
Date of Birth (To be completed only by applicants for Law Enforcement Advisory Board for purposes of
criminal history check to ensure compliance with 2.26.020 PAM C)
Certification and Location Information (Circleone)
Are you currently a City em.pIoyee> Yes o Are you a citizen of the United Statesry No
Are you aCity resident Yes Pio Do you own/'manage a business in the City? fees to
Do you hold any professional licenses,registrations or certificates in any field (list below)?" Yes l� �q
Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so,
please explain;
In compliance with the American Disabilities Act, if you will need special accommodations because of a physical.
limitation„please contact the City Clerk,417-4634,so appropriate arrangements can be made.
(OVER)
Work Experience
List most recent experience first(or elaborate on a resume if you prefer)
I.
Employer Your Title From(M/Y) To(M/Y)
Brief job description
2.
Employer Your Title From (M/Y) To(M/Y)
Brief job description
3.
Employer Your Title From(M/Y) To (M/Y)
Brief job description
Education
List most recent experience first
Yes No
1.
Institution/Location Credits earned/Major area of study Graduated?
Yes No
2.
Institution/Lo cation Credits eamedfMajor area of study Graduated?
Yes No
3.
Institution/Lo cation Credits 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
I.
Organization and location Group's purpose/objective #of members
Brief description of your participation
2.
Organization and location Group's purpose/objective #of members
Brief description of your participation
Why are you interested in serving on this particular Board or Commission?
(OVER)
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/Commission?_
Please feel free to add any additional comments you might wish to make regarding your application:
A 16 ticarat S a r'e Date
Submit completed forms to: Office of the City Clerk
City of Port Angeles
321 E.5th Street
P.0.Box 1150
Port Angeles,Washington,98362 12/08