HomeMy WebLinkAboutApplication 10/30/2014 I-"- <<� I � W � .
0 G T 0 n
L
'_'
CITY 01- 1F'0TFj7NGELE3
19GELEI CITY QLFRK
PQRT
101%" W A S H I N G T 0 IN, U. S. A.
APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE
Board,Commission or Committee to which you are seeking appointment:
Applicant Name and General Information
vtJ A
First MI Last
16, 0 -,-) roc 01V
Home Street Address
PO P-T
City State Zip
5 .7 - -77S
Home phone Work phone Cell phone
E-mail address
0-� /-)- -'),Z
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? &S No
Are you a citizen of the United States? No
Are you a Registered Voter? Ye No
Are you a City resident? es No
If so,how long IS I
Do you own/manage a business in the City? Yes No
Do you hold any professional licenses,registrations or certificates in any field? Yes (N 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: P 0 AJ t.
Work or Professional Experience-List most recent experience first,or attach a resume
j,6 I_t CA� - --
,M 0()-T PRODOC�TJON P"I\,AIE 6//aI/� ,/9, 0 0
Employer Title From(M/Y) To(M/Y)
coui- 14 rk V,11A (VOL4 (;t(,c� Me I- 014c �0,- for MS, C J Q ofJl- M 0'*Et�
ia I-
Brief job description
,2 -Ir-al. '7 b
C0
Employer Title Prom(M/Y) To(M/Y)
S;
�rilefjob de
1 scription
Employer Title From(M/Y) To(M/Y)
Brief job description
Education-List most recent experience first
10 Z—A r,4' C 4 P1 J)i V es No
Institution/Location Degree earned/Major area of study Graduated?
J - _B8 ("e No
Institution/Location Degree eamed/Major area of study ra uated?
o C_ L_ A os'// q
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
yr At,L,e /C f /years
r c r c 11,V, q 660-'w' p
co"J) 0J ltd 0
16
Organization/Location Group's purpose/objective #of members
Brief description of your participation: I�o Cis c'
pLe—M) l.'-.
c-,"i'5
V0 (U 04C(r /` b t( C' ec')"t ?
Organization/Location Gro'tip's purpose tiNre #of members
Brief description of your participation: (14 (4,_c,rg' j
C
0 1 C,
2 YK J
�'"/K AI 5
K ��/Ojj C' 4_��c i�1 0
I (1c,,Aco A
4 t
0
c 1 o I ri1 e R-ovfnr C,,5 1 m, C�d� CI 1 o
{ 7 (✓,A, r-aJ E;1/fNt GL t t\4(C 1 Yl 6h tS fa C.i I4k) „vt <
cait Cps r v tc " I(xeS Or- fir
42 e
Questions
Why are you interested in serving on this particular Board or Commission? /V �ok� u P o l rd"- I2)
"i ✓In Uil e �a GL_ W� '�c�'t u( �.r G Ck �1 K� 14^f s' Cc f� ff -�o
rcU u kKA �w�evi7- 11 0tlk(A'4 d )wAer6V),n
Lr��l r -hay AdofcorLy Jlrc,(J'l t�rav�� �'� Crh�GoU�rrt/�
62 0 0 r4 0" eS�d,�d �
l eve,r� Ur f�Gf/ C6r, t✓1(4
What in your background or experience do you vthink would help you in serving on th's Board?
4%, CUo U ttjacvl G2 /11 0U(� �ts �r,� �°b�y7lG✓)�
N
What is your understanding of the responsibilities of this particular Board or Commission
r �s tv,r/, O"�. c � VI U/ c S y //�0,1�av+/ c C r GC E
U < < 60U zie - CrJUiCa C 7 rC yCnoc,; tau
Please feel free to add any additional comments you wish to make regarding your application.
t7
7h< Cid €GSa I c
0— 3()
Applicant Signature Date
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. 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.
3