HomeMy WebLinkAboutApplication Young 01/04/2013 TAI
" �
4 '
Fa
APPLICATION FOR PPOINTMEN"I ,ro.BOA..III), CONIMISSION OIL COMMIT I
Board, Commission or Committee to which you are seeking appointment
w'
Applicant Name and General Information
m.... ......�
First _�NI Last
Home Street Address
qty State Zip �w
Florne Phone Work phone Cel l phone �
"LJ ...�t") I r?...?
..._ _ _.. _.. . ..._ ....wm.. .. _.. ... ._�........
l.. mail auclulre s
q ante of l artlr —(to" tae comp_ y a altcarrts for"'.'ul Iicc Safi,,t A(Tvisor I3oars9 for ur ao es of c-r-i' ...
aletert orrl l.ry:rp p y Y to p. s �rur�irral
history check to ensure compliance with Port.Angeles Municipal Code 2.26.020)
Certification and Location Information (circle one)
Are your employed by the City of fort Angeles? Yes LO)
Are you au citizen of tile United States': �ew1' No
Are you<r pity resident?
No
If so,flow long.
Do you own/manage ab business in the City? yes No
Do your hold any professional Iicenses,registrations or certificates in any field'? Yes (No
If so,please pint.
1.
Are you aware ofany conflict of interest which might arise by your servi cc on a City Board or Commission? If so,p]ease
.........."....... .....................
.............. . .................
Work Experience - List most recent experience first,or attach a resume
Employer Title From (�M/Y) To(NI/Y)
IV"
Briefjob description
....................
Employer Title From(WY) To(M/Y)
Briefjob description
........... ............
Ernployer Tide Froin(M/Y) To(M/y)
—---------
Briel"job description
Education - Ust most recent experience ffist
4
/,I C" 'e le< C e_1 No
CL .......................
i 2, .....�_Y' .." —)L
nsfitution/Location Degree earned/Ma or area Of 91—alcluated?
J
......................... Yes..---No .........
institution/Location Degree earried/Major area of study GradUated?
Yes No
drastitar —Degree earned/Majorarea ofstudy (.3—ra ci t
Charitable,Social and Civic Activities and Memberships - List major activities you have participaled in
during the last five years
-
................
01 nizati on/Location Grotjj�SPLH PO C,Objective
4 of members
Brief descript ion of your participation:_
..............(1 �. .......
A- (I e !q c'q
............................................. ....... ...................
Organization/Location GrOUP'S P11rj)OSC/0bJCCdVe It of members
Brief'description ofyour participation", ................. .......
..................................................................................... __............. .......... .................-------------------................ ........ ...... ....... ...... ................ ......
2,
Questious
Why are you interested in serving on this particular Board or Coniniission?
...... ...
7
Mat in Your backgl'OUnd or experience do you think would lielp You in serving on Illis Board?
Wilat is yourunderstandingof the responsibilities oftliis particular Board orCommission?
gym, b
11 L
------------
............
Please ficel free to add any additional con,inients you wisli to niake regarding your application.
................
..............
Date
Appjr6nt SigII'MUI-e V"
V
Submit completed foi-ms to: OFFICE OFTHE CITY MANAGER
'rERESA PIERCE,DEPUTY CITY CLERK
360-417-4630 or tPiCrCe@,CitY0fPa.US
City of'Port Angeles
32 l 1:3. 5",street
FIO Box 1150
Port Angeles,WA 98362
In com1fliance with the Americans with Disabilities Act, if yoti need special accorn niodat ions becmise of a physical
limitation, please contact the City Manager's Office al 417.4500 so aj)propriate arrangements can be made.
3