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HomeMy WebLinkAboutDodd Application 04/19/2016 • PORT ANGELES APR !j" WASH INGTON, U. S, A. 1 2016 CITY OF PORT ANGELES CITY CLERK APPLICATION FOR APPOINTMENT To BOARD, COMMISSION OR COMMITTEE Board, Commission or Committee to N%1-hich you are seeking appointment: I �Pd i r AAotS61-CA Applicant Name and General Information �0 L. - First MI Last Home Street Address f>Dy--E A-n�d 2S A q &67(�- city State Zip q 34 ! Horne phone Work phone Cell phone � (LA De )l i COM 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? Qyjes No Are you a Registered Voter? (Yes No Are you a City resident? Yes No If so,how long _ Do you own/manage a business in the City? Ye No Do you hold any professional licenses, registrations or certificates in any field? rYes) No If so, please list: 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 - 1-.ist most recent experience first,or attach a resume ..(74ws plovu— R&M0l5JY0Ja\/--.--- Employer Title From (M/Y) T (M/Y) C�a-Li 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 cd - 4 ,4 No Institution/Location Degree earned/Major area of study duat—ed? Yes No Institution/Location Degree earned/Major area of study Graduated? Yes No Institution/Location Degree earned./Major area of study Graduated? g Charitable, Social and Civic Activities and Memberships - List major activities you have participated in during the last five years V T�o Organization/Location Group's purpose/objective 4of members Brief description of your participation: L Organization/Location Group's PUPOSe/objective of members Brief description of your participation: 2 Questions W y are you interested in serving.t. �on this particular Board or Commission? , - = t�`? What in your background or experience do you think would help you in serving on this Board'? 5ft - What is your understanding of the responsibilities of this particular Board or Commission? - e � �- �' Please feel free to add any additional comments you wish to make regarding your application. t A ' ant Slgnature date Submit Completed forms to: OFFICE OF THE CITY CLERK JENNIFER VENEKLASEN,CITY CLERK 360-417-4634 or jveneklatai)cityofpa.us City of Port Angeles 321 E. 51h 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 417.4540 so appropriate arrangements can be made. a