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~ '~-OO~- .... ~.,J ~) ATTACHMENT C <br />AP CATION- APPOINTMENT TO ' <br />CITIZEN' ADVISORY BOARDS AND COMMISSIONS <br />Please Pdnt or Type. <br /> <br />Name ~.~ ~~.Co~. <br /> Fimt ~ Middle Last <br /> <br />DO you reside within th~,~ limits? ~es ~No If yes, how long? <br />C,~ Council Ward ... ~ ~/; ~ ~ Neighbo~ood Organization . <br />Home Telephone ~~- ~ ~ ~ Day Telephone ~- <br />OCcupation - ~ ~; ~. Pla~ of Employment <br />Business Address ... ' <br /> <br />F~ Number (if applicable) ~ail (If appli~ble) <br />How did you learn of ~is va~ncy? ~ Newspaper ~ Wo~ of mouth ~ Mail ~ Web Page <br /> <br />O~er Sour~ <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# 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 specific positions on the board/commission. <br /> <br />Please check the applicable boxes: <br /> <br />I~ Male [] Female <br /> <br />[] 18 and Under [] 19 - 25 [] 26 - 35 [] 36 - 45 [] 46 - 55 <br />[] 56 - 65 I]~/66 and above <br /> <br />[] African American [] American Indian/Alaskan Native [] Asian/Pacific Islander <br />[] Hispanic [] Middle Eastern [] MultiraCial <br />l~White/European American <br /> <br />Disability: [] Yes [~' No If yes, please describe <br />Fluent in languages °that than English? [~/Yes [] No VVhich language(s)? ,~' Ld('C_J/.~' ~_ <br /> <br /> P/ease complete both aides of this application Applimt;on for Appointment to C~en Advisory <br /> Revised September, 2001 - H:~Boards Committee~ commissions~CC~BCCAPP01091 <br /> <br /> <br />