HomeMy WebLinkAboutGlenn Wiggins for Civil Servicen
EC IVE
DEC I 4 2615
IJONTANGELES
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WASHINGTON, U.S.A.CuAu'?"
ArrLICATToN FoR ArroTNTMENT To BoARD, CoMMrssIoN on Coupurrm
Board, Commission or Committee to which you are seeking appoi,tment:
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Applicant Name and General Information
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Home Ste€t Address
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City State Zip
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Home phone
E-mail address
Work phonc Ccll phone
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Date ofBinh
Certification and Location Information (circte one)
Are you employed by the City ofPort Angeles?
Arc you a citizen ofthc United States?
Are you a Registered Voter?
Are you a City resident?
(to be completed oDly by rpplicsDts for Public Safet)' Advisory Board for purposes of crimirat
history check to eDsure compliaoce with Port Atrgeles Mutricipal Code 2.26.020)
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No
NoY
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Do you owr/manage a business in the City?
Do you hold any professional licenses, rcgistrations or cErtificates in any field?
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Yes (a6)Yes
Ifso, please lis:
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Are vou aware ofanv conflicl ofinlereste*prain: ,4/r.--
which mighl aris€ by your service on a City Board or Commission? If so, plcase
Work or Professional Experience - List most recent experience first. or attach a resume
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Employer Ti e
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From (M/Y) To (M,^r')
Briefjob description
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Employer Title From (M/Y) To (M/Y)
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Briefjob description
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Employer Title
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From (Mf() To (M/Y)
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Briefjob description
Education - List mosl recent exp€rience first
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lnstitution/Location
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Degree eamednr4 aj or area of study
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Charitablg Sociat and Civic Activities and Memberships - Lis major activities you have participated in
during the last five years
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Organization/Locati on
Brief description of your participation
Group's purpose/objectiveV*/fa.Yti-
# ofmembers
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Organizatiodlocation
Brief description of your participation:
Group's purpose/objective
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# ofmembers
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Questions
Why are you interested in serving on this particular Board or Commission?
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OI do vou think would hel p you m serung on Board?
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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Appl Signature Date
Submit completed forms to:OFFICE OT THE CITY CLERK
JE]\NIFER VENEKLASEN, CITY CLERK
3604 I 74634 or jvenekla@cityofoa.us
City of Port Angeles
321 E. 5t Street
PO Box I 150
Port Angeles, WA 98362
ln compliance with the Americans with Disabilities Act, ifyou.eed speciat accommodations because ofa physical
limitation, please contact the City Manager's Office at 417.4500 so apprcpriate arrangements can be made.
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What in your
What is your undersanding of the responsibilities
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