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HomeMy WebLinkAboutPeterson Application 01/27/2015 E C E, DWI PQRTANGELEIJAN 2 Y 2015 wW A S H I N G T O N, U. S. A. CITY OF PORT ANGELES CITY CLERK APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE Board, Commission or Committee to which you are seeking appointment: I A-P K �OIL R-I) Applicant Name and General Information 31L.L- E 1 C—p'sva First MI Last t-165- D E t.Otte S Pt.. Zz Home Street Address yR.T rtti&ELus WA 78U3 City State Zip ho -45a-oTO-(� Home phone Work phone Cell phone bt ll pe ol3petn.corms E-mail address 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 N� Are you a citizen of the United States? 6e s No Are you a Registered Voter? E) No Are you a City resident? Yes No If so,how long 31 �EA ItS Do you own/manage a business in the City? Yes �To Do you hold any professional licenses,registrations or certificates in any field? Yes No If so,please list: ASSISTA04r TA-*rr: GmmtrstonlEA-- �ASE,IjxTJ4 �kSGAALt- 1 Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so,please explain: No Work or Professional Experience-List most recent experience first,or attach a resume Ctrs off)itr A 1,J 6 t.as Rear- noN coortNNATDR 10/'m 1113 Empl yerr Title From(M/Y) To(M/Y) C ob"I NA-MP REC4Z.47.10M PtLftltAwJ Brief job description Employer Title From(M/Y) To(M/Y) Brief job description Employer Title From(M/Y) To(M/Y) Brief job description Education -List most recent experience first FaMMC. 13ratz C "Cd T aec Nt«s, Ao.e cA#4 DA NW-14)R., "%na-t Eou�cAT/oMt es) No Institution/Location Degree ea ned/Major area of study Graduated? 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 3Aas ZL m RAseyALi—~PoiaAwktass WLc6AL)-7htF-"�tra/ Deps !•J z Organization/Location Group's purpose/obje tive #of members Brief description of your participation: A ss i s r^-1r Sri Gt4u ttssi WeA LrJ C14AA66 OF Eae1+ lts"Al"6ar, QA6 TM,-ite•th"A-&r ExcAA ydkk t..q.rr 5- Ye.-As Organization/Location Group's purpose/objective #of members Brief description of your participation: 2 Questions Why are you interested in serving on this particular Board or Commission? De?oXTkWin To sM„E T14e. c4r-t-�-64s ©r~ PDX-Aa64%Es What in your background or experience do you think would help you in serving on this Board? )-D -t- 4EAXS L40XKtj& tl.t ?A*.Ks 4 tZSctt 4n04 jpkoGgN.s What is your understanding of the responsibilities of this particular Board or Commission? �2���1a��t&- ,�sr►srt•�c.� � r� �,M�cs � Re�r,��naN ��a Please feel free to add any additional comments you wish to make regarding your application. WOW-0 &C- Tim - U NLj omis o� r rE ..r wa�.,.c «ow tz t-vu rtay•a�r PAM" 0#A Applicant Signature Date Submit Completed forms to: OFFICE OF THE CITY CLERK JENNIFER VENEKLASEN,CITY CLERK 360-417-4634 orjvenekla@cityofpa.us City of Port Angeles 321 E. 50'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