HomeMy WebLinkAboutBartee Application, t,
CLALLAM COUNTY
BOARD & COMMITTEE APPLICATION
- Return Completed Application to:
Claltam County Human Resources -Department
223 E. 4th St., Suite 16
• :Poh.Ang%eles, WA 98362-W1.5; -
ClallArp County is an Equal Opportunity Efnplo.yer .
& Drug Free Workplace
FOR OFFICE USE ONLY
• 'INSTRUCTIONS .FOR COMPLETING TIJIS APPLICATION .. ;
• Complete the a lication thorou hl . Applications that are incomplete will not pe accepted. Resumes may be used to
supplement an application, but may not be used in lieu of completing the.appAcation form.
• Be sure to sign your name and enter the date you signed it where the application asks. Original signature is required. (scanned
and emailed copies will not be saved or usedj.
GENERAL INFORMATION:
Name (First, Middle Initial, Last): Name'of Committee: - Opportunity Fund Advisory
Johanna, A., BBartee
Category (if applicable): Board
Mailing Address:
123 Ruby Rd,
Residence Address (if different from above):
Same
Day Phone:
Evening Phone:
�225-7394
City, State, Zip:
Port Angeles, Wa., 98362
City, State, Zip:
I Email:
jjohannabartee@hotmail.com
Will you need access to a County computer: 0 Yes ID No Do you intend to drive, on behalf of the County: ❑ Yes 0 No
(If you said yes to the above question, a Driving' Abstract will be required.)
REFERENCES: , -
LIST THREE INDIVIDUALS NOT RELATED TO YOU WHO CAN PROVIDE JOB -RELATED OR CHARACTER REFERENCE INFORMATION ABOUT
YOU. NAME', ADDRESS AND PHONE INFORMATION IS R_ EQUIRED:
1. NAME OF REFERENCE W. Ron Allen RELATIONSHIPCEO O Cll"rrerit employer
ADDRESS 1033 Old `Blyn HWy, Sequim, Wa.' 98382
CURRENT PHONE (T 60) 681 -4621
Colleen McAleer Professional colleague
2. NAME OF REFERENCE RELATIONSHIP
ADDRESS ;338 .W 1st St:, Suite 105, Port Angeles; WA 9.8362.
CURRENT PHONE (360) 461-2218°
3. NAME OF REFERENCE Christopher Thomsen RELATIONSHIPP16feSSlonal collegue
ADDRESS 4253 NE 189th.AvenuePortland, Oregon '97230
CURRENT PHONE (816) 206-4716
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Revised 08/16; 11/17; 10/18
EXPERIENCE SPECIAL SKILLS & LICENSES:
Summarize your experience, special skills and qualifications, including hobbies:
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Place of employment, if employed:
Volunteer experience:A07d
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Special training/courses (include computer training): J.
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Are you fluent in any languages other than English? ❑ No 0 Yes. If yes, please list: S /J�4
ADDITIONAL INFORMATION:
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Explain why you wish to serve on this board/committee:
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Please describe your education/career background:
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Clallam County does not place volunteers in positions of direct supWNision by a relative. Please list any relatives (including
s Dose) employed by Ciallam County:
Name of Relative: Department:
Name of Relative: Department:
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Page 2 of 3
Revised 08/16; 11/17; 10/18
EMERGENCY CONTACTS:
Please list two eo le to natif in case of
Name: Marjory Bartee
Address: 86 Hunters' Gate Lane
City:, State & zip Code: Port Angeles, Wa., 98362
Phone: (Home) (360) 460-9795
Name: William Hart
Address: 123 Ruby Rd.
City:, State & zip Code: Port Angeles, Wa., 98362
Phone: (Home) (360) 775-5193
Notice to Volunteers
Relationship: Mom
(Work):_
Relationship: Spouse
(Worlk)
Volunteers are not considered to be Clallam County employees for any purpose. Injury compensation will be provided
as described in the service agreement. The data furnished on this form is furnished voluntarily and will only be used to
contact, interview and place volunteers in their assignments. Volunteers are expected to track all hours served on the
time sheets provided, This is a requirement for volunteering with Clallam County and provides supplemental injury
compensation, should that be necessary. Selection and dismissal as a volunteer is totally at the discretion of the
department head or elected official and may be with or without cause. No property rights are created by volunteering for
the County. NOTE: Based on questions answered in this document, additional training may be required.
AGREEMENT & CERTIFICATION:
I HEREBY CERTIFY, UNDER THE PENALTY OF PERJURY IN THE STATE OF WASHINGTON, THAT THIS APPLICATION CONTAINS NO
WILLFUL MISREPRESENTATION AND THAT THE INFORMATION GIVEN IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND
BELIEF. I AM AWARE THAT SHOULD INVESTIGATION ATANY TIME DISCLOSE ANY SUCH MISREPRESENTATION OR FALSIFICATION, MY
APPLI ATION MAY BE REJECTED, AND MY NAME MAY BE REMOVED FROM CONSIDERATION.
SIGNA RE OF APPLICANT DATE
To Anply:
❑ County Board & Committee Application
❑ Notarized Waiver and Authorization to Release Personal History Information
❑ Volunteer Disclosure Statement
❑ Confidentiality Agreement
Address or Deliver Packet To:
Clallam County Human Resources
Attn: Brenda Peterson
223 E. 41h Street, Suite 16
Port Angeles, WA 98362
Revised 08/16; 11/17; 10/18
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