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
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Applicant Name and General Information
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First MI Last
Home Street Address
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city State Zip
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Horne phone Work phone Cell phone
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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:
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Work or Professional Experience - 1-.ist most recent experience first,or attach a resume
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Employer Title From (M/Y) T (M/Y)
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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
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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?
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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 4of members
Brief description of your participation:
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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? ,
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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.
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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.
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