HomeMy WebLinkAboutApplication LeBer 07/27/2012 R FCE # VED
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PQ �� EE ��OtI ' Of Port Angeles
WASHINGTON, U. S. A.
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
First MI Last
Home Street Address
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city State Zip
,710-9-1
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? C9. No
Are you a City resident9 Yes No
If so,how
Do you own/manage a business in the City? Yes Flo
Do you hold any professional licenses,registrations or certificates in any field? es No
If so,please list:
Are you aware ofany conflict of interest which might arise by your service on a City Board or Commission? If so,please
explain:
Work Experience- List most recent experience first,or attach a resume
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Employer Title l-r�om(Ivf/y) TO(M/Y)
Brief job description
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Employer lite From 0(1V1 Y)
-B r'JfjblVesc�rip description
Title rorn(M/Y) T (M/Y)
Vmpl(�ye
Briefjob description
Education - List most recent experience first
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Institution/Location
Degree earned/Major area of study
Yes No
Institution/Location Degree earued/Maior area of study raduated?
Yes No
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Jti�titiiiurt ovation Degree carne area of
Charitable, Social and Civic Activities and Memberships- List major activities you have participated in
during the last five years
C)rganization/Location Group's purpose/objective #of mernbers,
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Brief description Of Your participation:_ ..........
Organization i,-(;L Group's purpose/objective of members
Brief description of your participatiow,
.......... ..................
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Questions
Why are you interested in serving on this particular Board or Commission?
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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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any additional comments you wish to make regarding your application.
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Applicant S OP- ate
'001i Signature
Submit completed forms to: OFFICE OF THE CITY MANAGER
City of Port Angeles
321 E. 5"Street
PO Box 1150
Port Angeles, WA 98')62
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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