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HomeMy WebLinkAboutApplication 03/17/2017 MAR 1 7 2M7 � WASHINGTON, U. S, A.PQRTANGELE1 �,.n„S ^rwwrw APPLICATION FOR APPOINTMENT T To BOARD,COMMISSION OR COMMITTEE Board,Commission or Committee to which you are seeking appointment: IC000-VS C6 leu yk Applicant Name and General Information C,L.>-- .t r First Ml Last Horne Street Address— A.C ddressA.0 0-(0- \A) � City State Gip Horne phone Work phone Cell phone :�Lr e45 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 ane) Are you employed by the City of Port Angeles? Yes o Are you a citizen of the United States`' e. No Are you a Registered Voter:' No Are you a.City resident`' Yes No If so,how long. .._....... ..._...v....... Do you ownlinanage a business in the City? No Do you hold any professional licenses,registrations or certificates in any field”? Yes 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 explaiw ............ ...... Work or Professional Experience- List most recent experience first,or attach a resume Title From(M/'Y) To('M/Y) ..... 441- ..... . ription Brief Job 41 96�4 i et Employer Tifle From(,M/Y) To(Mn,' A4 _cLo a AAU�r- av Brief job description ............. Employer Title From(MA') To(M/Y) Brief job description Education- usi most recent experience first 141U4!L-�--. Yes -ned/Maj o r-area I of study �Jradtiafe� Inslilution/Lo, tion Degree e ,i A4 No uat iraPd ed D gree carned[Major area of study Institution/11 ation -64( �YeNo— Institution/Location Degree earned/MaJor area of'study7" Graduated? Charitable, Social and Civic Activities and Memberships- List maJor activities your have participated in during the last five years �P4 '/.:� -A Organization/Location Group s purliose objective of members Brie f(leseri ption of your participation: /14 ....................... X .......... Organiz,kionl-ocation Groups purpose/objective i#of membersp Brief description of your participation: ...... ...... ..............--.................................................................... ....... 2 Questions Why are you interested in searing on this particular Board or Commission? Wu.,.'. 0 6�v �Ptc, a_VK�L4�a re ............ What in your background or experience do you think would help you in senring on this Board? k 2- ......... le'l Ue_� i K '0 ki. Mla�ULA­ _PUA What isyo ard Z Z�ommissin& )f x2V 4-, 0'e tA-r COP, Y---------- UA QV 6 0 _a_LA I Cf. ......(A t., (A' ...... ............. .......... 14y— 1 Vbt 11 Please feel free to add any additional comments you wish to make regarding your application. "J ........... —- ----- 1re Appl04n _i ture Date Submit completed forms to: OFFICE OF THE CITYCLFRK JENNIFER VENEKLASEN,CITYCLERK 360-417-4634 orjvenekla(e cityofpa.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 physical limitation,please contact the City Manager's Office at 417.4500 so appropriate arrangements can be inade. 3 ......................................................................---------------........................... . ..................................................