HomeMy WebLinkAboutApplication 03/17/2017 MAR 1 7 2M7
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APPLICATION FOR APPOINTMENT T To BOARD,COMMISSION OR COMMITTEE
Board,Commission or Committee to which you are seeking appointment:
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Applicant Name and General Information
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First Ml Last
Horne Street Address—
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ddressA.0 0-(0- \A) �
City State Gip
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 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
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Employer
Tifle From(,M/Y) To(Mn,'
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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
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No
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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
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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: ...... ......
..............--.................................................................... .......
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Questions
Why are you interested in searing on this particular Board or Commission?
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What in your background or experience do you think would help you in senring on this Board?
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What isyo ard Z Z�ommissin& )f x2V 4-,
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Please feel free to add any additional comments you wish to make regarding your application.
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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.
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