HomeMy WebLinkAboutApplication Irwin 01/24/2012 P EL
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Application for Appointment to a Board, Commission, or Committee
Board, Commission, or Committee to which you are seeking appointment:
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Board or Commission Full Name
Applicant Name and General Information
First MI Last
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Home Street Address
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City State� Zip Code
-7
Home phone number Work phone number
E-Mail Address: AA'-�
Date of Birth (To be completed only by applicants for Law Enforcement Advisory Board for purposes of
criminal history check to ensure compliance with 2.2(.020 PAMC)
Certification and Location Information (Circle one)
Are you currently a City employee? Yes Are you a citizen of the United States? �No
Are you a City resident? cso Do you own/manage a business in the City? Yes Pfi-o
Do you hold any professional licenses,registrations or certificates in any field(list below)? Yes(:o�
Are you aware of any co flict of interest which might arise by your service on a City Board or Commission? If so,
please explain:_ 4.,�
In compliance with the American Disabilities Act, if you will need special accommodations because of a physical
limitation,please contact the City Clerk,417-4634,so appropriate arrangements can be made.
(OVER)
Work Experience
List most recent experience first(or elaborate on a resume if you prefer)
Employer Your Title C/From(M/Y) To(M/Y)
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Brief ob description
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Employer Your Title From(M[Y) To(M/Y)
Briefjob dt-scription
3.
Employer Your Title From(M[Y) To(M/Y)
Briefjob description
Education
List most recent experience first
Yes (Nq)
Institution/Lo cation Credits earned/Major area of study Graduated?
Yes ":No
Institution/Lo cation Credits earned/Major area of study Graduated?
Yes No
3.
Institution/Location Credits 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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Organization and location Group's purpose/obJJ ective #dfembers
Brief description of your participation
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Organization'and location Group'dpurpose/oactive of
members 14�11'11>e.5
Brief description-0t your participation
Why are you interested in serving on this particular Board or Commission? �7
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(OVER)
What in your background or experience dcyou think �atichelpin s � . ths
Board:
What is your understanding of the responsibilities of this particular Board/Commission`?
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Please el free to add aaq;additional comments you might wash to make te&srdmg your application,
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Applicant Sig tat,re
Submit completed forms to: Office of the City Clerk
City of Port Angeles
321 E. 5th Street
P.0.Box 1150
Part Angeles„Washington,98362 12/08