HomeMy WebLinkAboutApplication 04/11/2014 1
PQRTAI�GELEI 2014
wAsrrINGroN, U. S. A.
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MY CLE[W
APPLICATION F O APPOINTMENT To BOARD, COMMISSION I'T'T EE
Board, Commission or Committee mittee to which you are seeking appointment:
Applicant Name and General Information
First --- — MI � � Last
Home Street Address
City State — _ zip ------_-.--
. ._.
Horne phone -- Work phone Cell phone --
Al
E-mail address
Date of Firth (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal—�
history check to ensure compliance with fort Angeles Municipal Code 2.26,020)
Certification and Location Information (circle one)
Are you employed by the City of Port Angeles? Yesfs
Are you a citizen of the United States? s No
Are you a Registered`Doter? " 0rs' No
Are you a City resident? s No
If so,how -
Do you own/manage a business in the City? €s No
Do you hold any professional licenses,registrations or certificates in any field? dg No
If so,please list:_ '
f
Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so,please
explain:
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Work or Professional Experience- List most recent experience first,or attach a resume
Employer Title From(M/Y) To(M/Y)
----------------------------- ........---------------- ------------------
Brief job description
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Employer Iritie From(M/Y) To(M/Y)
------------
Brief job description
Employer Title From(M/Y) To(M/Y)
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Briefjob description
Education - List most recent experience first
Na
Ins titu tion/Location Degree eamed/MaJor area of study 96dua ed?
\/,J A UA_ `Y;e' No
-------------- ...............
Institution/Location Degree carnedftajor area of study iduated?
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
<
Organization/Location Group's purpose/objective #of members
Brief description of your-participation: .....SdA 4
... .....
NJ
Organization/Location Group's purpose/objective #of members
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Brief description of your participation:_0 V' 6"—A, �,�> S� P�&�J r
------------------------------------------------- 4 ----
—---------- ---------------------
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Why are you interested io serving outhis particular Board or Commission?
What ioyour background or experience do you think would help you in serving cm this Board?
What is your understanding of the responsibilities of this particular Board or Commission?
Please feel free to add any additional cornments you wish to make regarding your application.
Applicallit Signature Date
Submit completed forms to: OFFICF0FTHE CITY CLERK
JANE0SAHmRD,CITY CLERK
360-417-4634or'bord@oityofbaua
City o[Port Angeles
921 B. 5"'Street
PV Box l|5O
Port Angeles, WA 98362
Tu compliance with the Americans with Disabilities Act,if you need special accommodations because ofophysical
limitation,please contact the City Manager's Office a14l7.45O0oo appropriate arrangements can bwmade.
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