HomeMy WebLinkAboutApplication Heckman 02/18/2016Jul 14 15 10:40p Sound Bikes & Kayaks 360 - 452 -0175
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W A S H I N G T O N, U. .1W OF OF FORT,> NGIR
JUL 1 5 2015
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:
Name and General Information
First
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Home Street Address
City State ip
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Home phone 1 Work phone Cell phone
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E -mail address
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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?
Are you a citizen of the United States?
Are you a Registered Voter?
Are you a City resident?
If so, how long
Do you own/manage a business in the City?
Do you hold any professional licenses, registrations or certificates in any field?
If so, please list:
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Yes
No
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Yes XO
Jul 14 15 10: 40p Sound Bikes & Kayaks 360-452-0175 p. 2
Are you aware of any conflict of interest which might arise by your service on a City Board or Commission? If so,please
explain: /�, r
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Work or Professional Experience- List most recent experience first,or attach a resume
yes 4�o�z
Employer Title From(MN) To(M/Y)
Brief job description
Employer Title From(M/Y) To(M/Y)
Brief job description
Employer Title From(M/Y) To(M/Y)
Brief job description
Education - List most recent experience first
N �s Yes o
Institution/Location Degree earned/Major area of study
Yes No
Institution/L.ocation 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
Organization/Location Group's purpose/objective #of members
Brief description of your participation:
Organization/Location Group's purpose/objective #of members
Brief description of your participation:
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?
What is your understanding of the responsibilities of this particular Board or Commission?
Please feel free to add any additional comments you wish to make regarding your application.
Applicant Signature Date
Submit completed forms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITY CLERK
360-417-4634 orjvenekla@cityofpa.us
City of Port Angeles
321 E. 5'b 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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