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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 MI Last
Home Street Address
City State Zip
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I-lome�hone C.I -�
P Work phone Cell phone
E-mail address t
Date of firth (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 /
Are you a citizen of the United States? Oe No
Are you a City resident? (Yes) No
If so,how long_ ` --- ��G i�C`°. -----
Do you own/manage a business in the City? yes C DO
Do you hold any professional licenses, registrations or certificates in any field? Yes �No�
If so, please
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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:
Work Experience - List most recent experience first, or attach a resume
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Title qF nM
Employer /i Y) o M/N
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Brief job description
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Employer Title From(M/Y) To(M/Y)
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Brief job description
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Employer Title Fro'rn (M/Y) To(M/Y)
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Brief job description
Education - List most recent experience first
Y V" v I op,:� No
Institution/Locati6n Degree earned/Major area of study Graduated?
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Institution/Location Degree earned/Major area of study Graduated?
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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
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Organization/Location Group's purpose/objective 9 of members
Brief description of your participation: k C-Oc
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Organization/Location Group's purp�se/objecti�vc 9 of members
Brief description OfYOUr participation:
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Why are You interested in serving on this particular Domd mrCommiuoion?
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What in your background or experience do you think Would help YOU in serving,on this Board?
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What is your understanding of the responsibilities of this particular Board or Corni-nission? /
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Please feet free to add any additional coi-nmClItS You wish to rnake regarding your application.
Applicant Signature Date
Submit completed forms to: OFFICE QPTHE CITY MANAGER
1[QRESA PIERCE,DEPUTY CITY CLERK
360-417-4630 ortpiovoe@cityofpo.um ^
City o[Port Angeles
321 E. 5 m Street
9O Box 1 |5O
Port Angeles, VYA 98362
In oomy|iancc with the Americans with Disabilities Act, if you need special accommodations because o[uphysical
\imiCadoo, please contact the City Managet's Office at 4 17.4500 so appropriate arrangenients can be niade.
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