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Home My WebLink AboutApplication Smith 12/18/2017 Q��'TANGELES W A S H I N G T O N, U. S. A. APPLICATION FOR APPOINTMENT TO BOARD,,COMMISSION OR COMMITTEE Board, Commission or Committee to which you are seeking appointment: _._ Applicant:flume and General Information First M1 St 5 Horne Street Address hbi " y � este Zip 27 Home phone Work phone Cell phone 4,.. 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 Part Angeles? Yes Q<P Are you a citizen of the united States: No Are you a Registercd.Votee? @^��°�r es,,k No Are you a City resident'? "��Yes,, No If so,how longi µ Irpo you own/manage a business in the City? Yes P Ido you hold any professional licenses,registrations or certificates in any field? e s leo If so,please list; :` l Are you aware of any conflict of interest which nrigJit arise by your service on a City Board or Coinniiision? If so,please explain: Work or Professional Experience-List most recent experience first,or attach a resurne 41 ........... 7 Employer Title From(M/Y) To(M/Y) iiief job description nployer Title FroFrom(M/Y) To(WY) ,i —Bric�J;bdfe'!ription Employer Title From(M/Y) TO(M/Y) giiefjob Education-List mast recent experience first _YO_Np Institution/Location Degree earncdaMajor area ofstudy Graduated? Yes Plea Institution/Location Degree earned/Major area of study Graduated? Yes No Degree canted/Major area of'study Graduated? Charitable, Social and Civic Activities and Memberships-List major activities you haNT participated in during the last five years Orgmuzittion/Location Group's purpose/objective #o if nnree n ibb Brief description of your participation:_. 4" zation/LA)cation Group's purpose/objective #of members Brief description of your participation:,_ __,_ 2 Questions Why are you interested in serving on this particular Beard ora Commission? y y p y n this Board: What in our background or experience do you think would het you in se bn o ,,P a LL k 6V 4,�� uA .5 C, 0 j,M nc �._ at is your understanding of the responsibilities of this particular Board or Commission? uV"'V r .......... Please feel free to add any additional comments you wish to make regarding your application. " e,. a .Applicant Signature Date Submit completed forms to: OFFICE E car THE CITY CLERK JENNIFER R ENI+LASEN,CITY CLERK 360-417-4634 orjvenekla@,cityo1`pa.us City of Port.Angeles 321 l3. 5,h Street Fort 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.. 3 { o Sn;y'- Gre) 4i 7 -7777 Public Safety Advisory Board additional questions: If"yes", please describe your experience? 3) Is a particular area ofpublic safety that specifically interests you? enforcement Fire 9l I / Dispatch Emergency Management Emergency medical services 4) Are you interested in participating in an annual and scheduled "ride along" with both Police and Fire/EMS personnel? /eS 5) What issue(s) are the most pressing issue that impacts public safety in Port Angeles? l) Have you ever been employed in a public safety position or worked in the public safety profession? 1/, 2) whatisitthatinterestsyouabourpublic sateVZ fi hetp *h_ h"^u/nE>44t{ ,/"ug od;:+", ffi A.l +.1h.- roo+ c-qu(se.- OY Ane Sttcicte epil-e.Wic, c d e Dr,e * a"!lr.{ion.