HomeMy WebLinkAboutBailey Application 04/18/2017 S� w
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APPLICATION FOR APPOINTMENT To BOARD,COMMISSION OR COMMITTEE
Board,Commission orpCommittee to which you are^ seeking appointment: �
Applicant Tame and General Information
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First loll Last
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Home Street`Address
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City J State Zips
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Home phone Work phone Cell phone
E-mail address
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Tate of Birth (to be completed only by applicants for Public Safety Advisory Board for purposes of criminal
history check to ensure compliance with Port Ankles Municipal Code 2.26.020)
Certification and Location Information (circle one)
Are you employed by the City of Fort Angeles"? Yes C No')
Are you a citizen of the United States? i'es w"i o
Are you a Registered Voter"? Yes Nom
Are you a City resident? Yesq No
If so,how long_ ...._.._.._ ._......
Do you own/manage a business in the City? Yes
Tao you hold any professional licenses,registrations or certificates in any field? Yes NP
If so,please list:m 4
1.
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- List most recent experience first,or attach a resume
Employer Title From(M/Y) To(M/Y)
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
N�wrxe�p� Yes &)
lnstitution/Lcation Degree earned/Major area of study Gradua�&a?
Yes) No
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Institution/Location Degree canned/Major area of" udy r bated?
Yes No
Institution./Location Degree earned/Major area of study Graduated?
Charitable, Social and Civic Activities and Memberships-List major activities you have participated in
during the last live years
Organization/Location �(2Af)up's purpose/objective #of members
Brief description of your participation:
vo 1j L) -er
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Nil
Organization/Locatiord Group's prpose/ bjective #of members
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Brief description of your participation: A yL 6 p, C e
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Questions
Why are you interested in serving on this particular Board or Corrunission t
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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 corn:ments you wish to niake regarding your application.
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r4p nt Slgnat e , Date
Submit completed farms to: OFFICE OF THE CITY CLERK
JENNIFER VENEKLASEN,CITU CLERK
360-417-4634 or j-venekla(dr cityofpa.us
City of Port Angeles
321 B. S"'Street
Port Angeles,WA 98362
In compliance with the Americans with Disabilities,pct„ if you need special accommodations because of a physical
limitation,please contact the City Manager's Office at 417.4500 sr appropriate arrangements can be made.
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