HomeMy WebLinkAbout Application Shargel 02/16/2016 N ®RT AI FEB�t GELES 'Fill, i 2016
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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 /�
_'P - q�City State Zip
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Home phone Work phone Cell phone
E-mail address
Date of Birth (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 No
Are you a citizen of the United States? `Yes,) No
Are you a Registered Voter? (..Y,0 No
Are you a City resident? (, Ye) No
If so,how long
Do you omihnanage a business in the City? Yes Nto
Do you hold any professional licenses,registrations or certificates in any field? Yes �Z-11
If so,please list:
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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(V-1)111/Y)
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Brief job description
Employer Title From(M/Y) To(MN)
Brief job description
Employer Title From(M/Y) To(M/Y)
Brief job description
Education - List most recent experience first
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V° /--J /y,'/ ")iy Yes No
Institution/Location 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 Gradua ed?
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
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Brief description of your participation: U�l nil v- v i pv
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Organization/Location Group's purpose/objective #of members
Brief description of your participation: i �' G f�� �� ti�� � > 1� t S�/O;^✓l>�
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Questions
Why are you interested in serving on this particular Board or Commission?
What in your background or experience do you think would help you in sery ng on this B ard? _
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What is your understanding of the responsibi ities 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.
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Applicant Signature Date
Submit Completed forms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 orjvenekla@cltyofpa.us
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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