HomeMy WebLinkAboutSuhr Application 01/08/2016 D
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PPRTA GALES 8 2016
►1t WASH I N G T O N, U. s. A. CITY OF PORT ANGELES
<. _ CITY CLERK
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APPLICATION FOR APPOINTMENT TO BOARD, COMMISSION OR COMMITTEE
Board, Commission or Committee to which you are seeking appointment:
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Applicant Name and General Information
First MI Last
Home Street Address
P0 q9363
City State Zip
3 h o 772,c
Home phone Work phone Cell phone
E-r ail address
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 No
Are you a citizen of the United States? Yes No
Are you a Registered Voter? Yes No
Are you a City resident? Yes No
If so,how long � Y,(Z .
Do you own/manage a business in the City? Yes No
Do you hold any professional licenses,registrations or certificates in any field? Yes No
If so,please list: - � u 2� Ci�1�[/k'/ ' to I r
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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 or Professional Experience - List most recent experience first,or attach a resume
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Employer Title From(M/Y) To(M/Y)
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Brief job description J
Employer Title From(M/Y) To(M/Y)
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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
Education - List most recent experience first
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Institution/Location Degree earned/Major area of study ated?
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
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Organization/Location Group's purpose/objective #of mem`6ers
Brief description of your participation:
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Organization/Location Group's purpose/objective #of members
Brief description of your participation:
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Questions
Why are you interested in serving on this particular Board or Commission?
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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 additi2!IW comments you wish to make regarding your,application.
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Applicant Signaffrre Date
Submit Completed forms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 orjvenekla@cityofpa.us
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City of Port Angeles
321 E. 5"' 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.
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