HomeMy WebLinkAboutApplication Garcia 08/09/2012 8 "
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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 lull .... Last
Home Street Address
N,..
City � _ p
State
Home phone Work phone Cell phone
E-mail addr , ' ^�� —
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 ane)
Are you employed by the City of Port Angeles"? Yes 0
.Are you a citizen of the United Mates? �..,Y No
Are you a City resident? 1WYes No
If so,how long
Do you own/manage a business in the City? Yes
Do you hold any professional licenses,registrations or certificates in any field? te-5�> No
If so,please .._...__.._.,..... ....
Are you aware of`any conflict of interest which might arise by your service on a City Board or Commission? If";o,please
explain:
Work Experience- first most recent experience first,car attach a resume
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Em
player Title
r
Briefjob drr'ptaon:.... r fit. y.. '... _ ..? .. ......:
:°_
Employer Title rout i,
�m
Briefjofa description
ey
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lal()yer Title FroiasIM YB
Brief'poli description
Education - Ust most recent experience first
Institution/Location Degree earned/Major area of study aduated'
� .�.� _... � .... .
.' ,ry . . ....... _ NO
Institution/ Degree ( raduatcdaan ar —
Yes No
Institution/Location Degree earned/Magor area ot`study 6r;rduated?
Charitable,Social and Civic Activities and Memberships - List major activities you have participated in
during the fast five years
Organi/.ation/I.,ocation Group's purpose/objective cal''nIear7lVrs
Brie Nescription ofyour participation:
.. %4 ywf`otic nil r°
Organization/Location Group's purpose/objective
Brief'descriptior of your participation __.___._
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Questions
Why are you interested in serving on this particular Board or Commission"?
ZY
..,._
..... ., a 4A„_.fir`
What at your backgMi.ind o_r._.experience
...d....o yo�u.think would
" help.you i serving n this Board
o-.
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v
If �"�
What is your understandingof the responsibilities
Itis particular Board ca¢ C"t�txtn"�ossic�aa°:'
' o t
x
y ^� _ ra��;arc ani,your application.
Pleasefeel free to add any additional� �.._.you� �make.
comments wish t
pp aeantu�gnatt :. ....._... Date
Submit completed forms to: OFFICE OFHE CITY CMIA"s.4GER
City of Port Angeles
3 2 l E.5'h Street
PO Box 1150
Port Angeles, W 98-162
In compliance with the Americans with Disabilities Act,if you need special accoin rnodat ions because;ofea physicaG
limitation,please contact the City Manager's Office at 417.4500 so appropriate arrangements can lie made.
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