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Mar 18 2005 12:~?PM Lane Community College 541 -463-33?0 p. 1 <br />'~ ' A ~ RECEIVED <br /> <br /> APPLICATION FOR APPOINTMENT TO MAR 1 ~ 2005 <br /> CITIZEN ~VISORY BO~DS AND COMMISSIONS' <br /> P/e=se Pd~t or Typ~ I I <br /> <br /> ~fr~ Middle Lest <br /> S~r~t C/~y Zip <br /> <br /> City Cou ncil Ward <br /> r Neighborhood Organization <br /> <br /> How did you lea~ of this vacancy? ~ Newspaper ~ Word of mouth ~ Mall ~ Web Page . <br /> Other Source <br /> <br /> OPTIONAL INFORMATiON <br /> The Eugene City Council 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 Counc~7 to know if the appointments match the diversity of the <br /> community. Applicants are considered without regard lo race, sex, color, national origin, age, religion, marital sl'atus, medical <br /> concift/on, or disability. In some instanceS, however,- appointment to certain beards/commissions may be based upon the <br /> need to fill specific positions on the board/commission. <br /> <br /> Please check the applicable boxes: <br /> <br /> [] Male [] Female <br /> <br /> [] 18 and Under [] 19 - 25 [] 26- 35 [] 36 - 45 [] 46 - 55 <br /> [] 56 - 65 [] 66 and above <br /> <br /> [] African American [] American Indian/Alaskan Native [] Asian/Pacific Islander <br /> [] Hispanic [] Middle Eastern [] Multiracial <br /> [] White/European American <br /> <br /> Disability: [] Yes [] No If yes, please describe <br /> <br /> Fluent in languages other than English? [] Yes [] No Which language(s)? <br /> <br /> I:leas~ complete bofh ~ides of ~i$ application Applical. ion 1or/~ppolntment ta Citizen Advisory Boards and Coll~lisslons- Page 1 <br /> R~vlsed Seplernber, 2~01 - P:~CMO~BCC~BCCAPP010al 1B,wpd <br /> <br /> <br />