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,--" ~EIVED :~ BY Cl~, )MANAGER APPLICATION FOR APPOINTMENT TO HAR 0 9 2005 CITIZEN ADVISORY BOARDS AND COMMISSIONS Please P~nt or Type. Board or Commission ~ ~L~ ~~ ~K ~TIZE~ %~N~I~ ~, Name ~ LLI O~ ~ ~D~ ~ ~1~ ~ ~ E Fi~t Middle La~ Stmet Ci~ ~ Zip Do you reside within the City limits? ~Yes ~ No If ~s, how long? ~ ~ O. City Council Ward ~ Neighborhood Organization HomeTelephone ~ 4-2~1~ Day Telephone ~ Occupation ~N~V. ~0 ~~ -~1 ~E~ Place of Employment Business Address ~ Fax Number (E applicable) ~ E-Mail (If applicable) ~}~ ~''~ ~ ~~ q~ ~ HOW did you learn of this va~ncy? ~ewspaper DWord of mouth D Mail ~Wob Page Other Source OPTIONAL INFORMATION The Eugene Ci~ Counc8 suppose diversity and seeks to appoint persons who represent ~e divers~y of ~e community. By providing ~e in~rmation below, you can help the C~y Council ~ know if the appoin~ents match ~e diversity of the community. Applicants am considered without regard to race, sex, colo~ national origin, age, religion, marital status, medical condition, or disabili~. In some instances, howeve~ appointment to ce~ain boards/commissions may be based upon the need to fill specific posi~ons on the boa~/commission. Please check the applicable boxes: ~ Male D Female [] 18 and Under [] 19-25 [] 26-35 [] 36-45 []46-55 1~56 - 65 [] 66 and above [] African American [] American Indian/Alaskan Native [] Asian/Pacific Islander [] Hispanic [] Middle Eastern [] Multiracial ]~W hite/European American Disability: [] Yes ~ No If yes, please describe Fluent in languages other than English? [] Yes '~ No Which language(s)? P/ease complete both sides of ~hi$ application Application for Appointment to Citizen Advisory Boards and Commissions- Page 1 Revised SepBmber, 3001 - P:\CMO~BC(ABCCAPP0109119,wpd