HomeMy WebLinkAboutApplication 01/28/2014 D
PJAN 2014
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WAS HINGTON, U. S. A. CJTY OF POR- NGELES
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APPLICATION FOR APPOINTMENT 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 MI Last
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Home Street Address
A.117
City State Zip
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-_52 -7021 ' 77 2(40Y
Home 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
Are you a citizen of the United States? 00s) No
Are you a Registered Voter? (]Ye No
Are you a City resident? Yes
No
If so,how long YFO
Do you own/manage a business in the City? Yes
Do you hold any profess ibnal licenses,registrations or certificates in any field? Yes
If so,please list:
Are you aware of any conflict of interest which might arise by your service on a City Board or Conirm
gi sion? If so,please
explain-
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Work or Professional Experience - List most recent experience first, or attach a resume
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Employer Title /,;I From(M/Y) To(M/Y)
Brief jab description
Employer Title From(MJY) To(M/Y)
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Brief job description
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Employer — Title From(M/Y) To(M/Y)
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Brief job description
Education - List most recent experience first
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Institution/Location Degree camed/Major area of study )rradi iated?
Yes No
Institution/Location Degree calmed/Major area of study Graduated?
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 five years
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Orgaiiization/Location Group's purpose/objective #of members
Brief description of your participation: AlAw 74�
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Organization/Location Group's purpose/objective 9 of members
ABrief description of your participation: ,11 A f,
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Questions
Why are you interested in serving on this particular Board or Commission?
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Whqt 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?
Please feel free to add any additional comments you wish to make regarding your application.
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Applicant Signature Date
Submit completed forms to: OFFICE OF THE CITY MANAGER
TERE sA PIERCE,DEPUTY CITY CLERK
360-417-4630 or tpierce@cityofpa.us
City of Port Angeles
321 E. 5`i' 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 417.4500 so appropriate arrangements can be made.
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