HomeMy WebLinkAboutApplication Remlinger 01/15/2013 ............
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APPLICATIONFOR APPOINTMENT To BOARD,,COMMISSION OR MITT '<
you pare shaking appointment:
Board, otnn�issita r r��nnaitttw ttr� rytvvfaicit
Applicant Name and Greneral Information
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First lull Last
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1-lonre Street Address
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City State Zip
1lonie plronc Work phone Celli phone .�,�.... ..�.
1? mall address ._
fDato cat 13arthIT (to lie completed only by apl)"lrcantsW f,or 1°ublic Safety-tdv°isory hoard far 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? Yes NIO
Arc you a citizen of the United States? Yus No
Are you a City resident? No
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Do you owndananage a business in the City? Yes
Do you bold any professional licenses,registrations or certificates in any field? Yes
If so,please list
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Are you aware of any conflict of interest which rnigbt arise by your service on a City Board or Cornmission? If so,please
explain:
Work Experience-List most cent experience first,or attach a resume
Employer Title From(M/Y') To(m/y)
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Bricfjob description
:Ernploycr Title From(M Y) TO(M/Y)
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Bricf job description
Employer Title Froi 71 y To(MN)
4752 s
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Brief job description
EdYcation -List most recent experience first
Yes
I stitution/Location Degree earned/Major area of study Graduated?
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In, 'itution/1.0cation Degree earned[Major area of study Graduated?
Yes
N.
Instihition/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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--i�Location Group's purpos'e/o-b—jective —of
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Brief description of yourparticipation:
6rjanization/Location Flrc;nP-s purpose/objective #of members
Bfief description Of YOUr participatiom
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Questions
Why are you interested in serving on this particular Board or Commission'7
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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 Commission?
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Please feel free to add any additional comments you wish to make regarding your application,
Ap�ribati 9" e
Si Date
Submit completed forms to: OFFICE OF THE CITY MANAGER
TF,RFSA PII�Rcrs,DE,PUTY CITY CIS' 'I'
3604174630 or tpierce@cityolpa.us
City of Port Angeles
32,1 E. 5'd`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
limit,ation.,please contact the City Manager's Office at 417.4500 so appropriate arrangements can be made,
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