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<br />FROM <br /> <br />FAX NO~ <br /> <br />ATTACHMENT B <br />REceIVED <br />APPLICATION FOR APPOINTMENT TO BY ~1 ~t~~~ER <br />CITIZEN ADVISORY BOARDS AND COMMISSIONS t <br /> <br />Pleaae Print or Type. <br />Board or Commission ~ t.. <br /> <br />kt?PLK~C~ 7~..o~H";> <br /> <br />(Q <br />~ <br /> <br />Name <br /> <br />~, MbQ <br />FIrst <br />.S-S-~ 3 <br />h..... <br /> <br />Street <br /> <br />1< <br />. Middl. <br />&:.It/IA~lirr;W -Arlo ~f,A..)l. <br />City <br /> <br />1lJTlW <br />Last <br />q =t!~o 2 <br /> <br />Home Address <br /> <br />ZIp <br /> <br />Do you reside within the City limits? <br /> <br />liIyes DNo. <br /> <br />l"ye8. how long? <br /> <br />8 of- ~Ir.. ') <br /> <br />City Council Ward <br /> <br />Neighborhood Organization <br /> <br />HomeTelephone -s:ifl-- 5';}D-'?0l9S DayT.le~hone $"~/'" 33S'-633.s- <br />Occupation :;:;;A1~_'QD1V1tL. ~ct.u..welf ~ Place of Employment ~V' I Tl2.0~LA) <br />Buelne88 Add,.." .21 ~ I W Ii.. L ~ CtLt..{./( 1;'~ fu" iN ~ tj 1r'o 2- <br />Fax Number (If applicable) '::[lfl... ~~ ...tmS1r E-Mail (If appDcable) 7lE,A-IQ .?Ifttt{ (i) (j)""~DGVJ · ~ <br />How did you leam of this vacancy.? o New8p8per UlwOrd of mouth o Mall Dweb Page <br /> <br />Other Source <br /> <br />OPTIONAL INPORMA TlON <br />The Eugene City CounoH aupparl.s diversity and seeks to appoint perBonswho represent the diversity of the community& By <br />providing the information below, you can help the City Council to know If the appointments matoh the diversity of the <br />communltY4 AppJk;ant$.ffJ consIdered without regard to race, sex, color. national origin, age, religion, marital status, medical <br />condition, or dlsablHty. In some instances, however, eppolntment to certain boardS/oommiss;ons may b. based upon the <br />need to fiB apeclio position$ on the board/oommlss/on. <br /> <br />Please oheck the IIppflcable boxes: <br /> <br />IL Mal~ <br /> <br />CJ Fem.le <br /> <br />018 and Under <br /> <br />[J 19 - 25 <br /> <br />IiH6 .. 35 <br /> <br />[J 36 ... 45 <br /> <br />o 48 - 55 <br /> <br />o 66 - 66 <br /> <br />CJ 88 and above <br /> <br />CI African American 0 American Indian/Alaskan Native <br />Cl Hlspanie D Middle Eastern <br />ILw hlta/European American <br /> <br />(J AslanlPaclflc Islander <br />o Multlraelal <br /> <br />D IS8 bUlly: <br /> <br />CJ Yea <br /> <br />r2I- No <br /> <br />I.f yes, please. deBcrlbe <br /> <br />Fluent In languages other. than English? 0 Yes <br /> <br />. liJ-No Which language(s)? <br /> <br />PIe". t:t)mIJ/et. both aides of thIa .plJt>>tlon <br /> <br />AppfIOllttot\ Jot ,fppoIntmenl. 0IDIIn ~......, ~ fit.,. i <br />~vlHd Seplember. Z01 .. ~\ICC\B(XWIP010tn 1'.wPd <br />