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<br />~. <br /> <br />ATTACHMENT C <br /> <br />, <br /> <br />APPLICATION FOR APPOINTMENT TO <br />CITIZEN ADVISORY BOARDS AND COMMISSIO.NS <br />Plesse "Prlnt or Type. <br /> <br /> <br />a'oard or Commission I.an~ Wnrk-fnrr!A Partnenship <br /> <br />Name <br /> <br />niane <br /> <br />First <br /> <br />K. <br />Middle . <br /> <br />Wiley <br /> <br />Last <br /> <br />Home Address 5111 ~nl~r HAiqhts <br />Street <br /> <br />Euqene <br />City <br /> <br />97405 <br /> <br />Zip <br /> <br />Do you reside within the City limits? <br /> <br />DYes 0 No <br /> <br />If yes, how long? ? t\ YI3~ r R <br /> <br />City Council WaMi=tTn , <br /> <br />Home Telephone, 9 i 44 J 1 <br /> <br />Neighborhood Organization <br />Day Telephone 346-5566 <br /> <br />OccupatloODi rer-f-nr I 'Ri v~rfrnnt Res - Park Place of Employment UO <br /> <br />Business Address 1 27 €i, YO, EugQtlQ, O'R 97.4 n ~ -1 ? 7 f\ <br /> <br />Fax Number (If applicable) "3 ~ 6 f\ 1 q 7 <br />How did you learn of this vacancy? 0 Newspaper <br /> <br />E-Mail (If applicable) dwilev@uoreqon. edu <br />f9word of mouth o Mall OWeb Page <br /> <br />Other Source <br /> <br />OPTIONAL INFORMA TION <br />The Eugene City Coune' supports diversity and seeks to appoint persons who represent the diversity of the community. By <br />providing the Information'below, you can help the City Council to know If the appointments match the diversity of the <br />community. Applicants are considered without regard to race, .sex,color, national origin, age, religion, marital status, medical <br />condition, or disability. In some Instances, however, appointment to certain boards/commissions may be based upon the <br />need to fill specKle positions on the board/commission. <br /> <br />Please check the applicable boxes: <br /> <br />o Male <br /> <br />jfk"Fe.male <br /> <br />o 18 and Under <br /> <br />o 19 - 25 <br /> <br />o 26 - 35 <br /> <br />o 36 - 45 <br /> <br />046 - 55 <br /> <br />o 56 · 65 <br /> <br />o 66 and above <br /> <br />o African American 0 American Indian/Ah~skan Native <br />o Hispanic 0 Middle Eastern <br />~ White/European American <br /> <br />o AslanlPaclflc Islander <br />o Multiracial <br /> <br />o Isa bUlly: <br /> <br />D. Yes <br /> <br />xia No <br /> <br />If yes, please describe <br /> <br />Fluent In"languages other than English? JfJ Yes <br /> <br />o No Which language(s)? Spanish <br /> <br />,r.-....~. <br /> <br />Please complete both sides of thIs application <br /> <br />AppUcatlon for 19potntment to CItIzen A<M8ory Boards and ConmInIons- Page 1 <br />Revised September. 3lO1. P:\CM:)\8CC\BOOAPP0109119.wpd <br />