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<br />RECEIVID. <br />BY CfTY MANAGeR <br />APPLICATION FOR ApPOINTMENT TO OCT 1 0 2006~ <br />. CITIZEN ADVISORY BOARDS AND COMMISSIONS. .. <br /> <br />I-Iolne Address <br /> <br /> <br />A f;or l/~n .Jd5j 6th' */ Lt'/4.r1ctQe m &;IT <br />c;~~/S'$~n (.AI WAC) / . <br /> <br />~e~/c- <br /> <br />Name of Board, Com:mlssi,o:n,or Cornlnittee <br /> <br />Please print or type <br />Name <br /> <br />Home Telephone <br /> <br />,Dayti me' Tele,pl1.o.ne <br /> <br />6"8r6<,'9o <br /> <br />Do you reside within the city lianits? t;(Yes <br /> <br />aNo <br /> <br />If yes, ~ow long? <br /> <br />28 y;~/J <br />/' <br /> <br />City Council Wurd I N'eighborhood Orgarijzati.on . .~~oIAt <br />. . .' / <br />Occupation/Place of Employment tJ/J CiC t;;~47 ~ ;",<,e-'.5 <br />Business Address . '20 C:;vn iy. C /v4.~"~Rc~-!. <br />Fax number (if applicable) 68J.- 6..5 7' EiuaH (ifapplicable) J e,.A@ ~.6~~.. <::'h.....n <br />How did you le~rn of this vacancy? Q Newspaper .;~v ord of Mouth CJ Mail (J Web page <br /> <br />Other source <br /> <br />NOTE: Irif'Jrtnation cOl1sistiilg ojholne addresses and phone l1un,bers Itlay be exel1tptfto111 disclosure,per ORS 192.502(3). <br /> <br />OPTIONAL .INFORMATION <br />The Eilgene City COllncl1 supports diversity and seeks to appoint persolt~who represent the diversity ofthe'co?nHll!nity. B)J <br />providing the inforlt/alion belo)i',you can hell) the Ciiy Council ((i.kI101t' ij.the appoinll't?ents i1l01cl1 the diversity. of'th~ <br />cOf1l1llunity. Applicants are considered lvithout regard 10 race, sex,. color, nation,a/ origilf~ age, religion; lifarital ~.l(ltus, <br />lnedical condition, or disability_ lnsoln-e instances; hOlvevel~ appoil1tn,el1t tocertainboart/s!CQI111lfissiol1s,Jltay bebclsed ul,on <br />the need to,{ill specific positions on the board/c0I1I-n,isslo17. <br /> <br />"Male <br />CJ 18 and under <br /> <br />(J FClnale <br /> <br />Q 19-25 <br /> <br />Q 26..35 <br /> <br />o 36.45 ~6-55 <br /> <br />fJ 56-65 <br /> <br />Q66+ <br /> <br />CJ African Anlerican <br /> <br />CJ .A:merican lndianl Alaskan Native <br /> <br />I:l Asian/P~cific Is lander <br /> <br />a flispanic <br /> <br />CJ ,Middle Eastern, <br /> <br />.a::WhiteIEuropean A.lnerican <br /> <br />Q Multiracia I <br /> <br />Disability? <br /> <br />aYes <br /> <br />~1j(j <br /> <br />If yeS~ please describe, <br /> <br />Fluent in language(s) other than English? (J Yes <br /> <br />~o "" If yes , please list ______u <br /> <br />F:\PERSDIR\OERU006BCCnpplicntion. doc <br />