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ATTACHMENT C <br /> RECEIVED <br /> APPLICATION 'FOR APPOINTMENT TO BY CITY MANAGER <br /> CITIZEN..r ADVISORY BOARDS AND COMMISSIONS , , M/~Y ¢)r; ')nnr: <br /> Please Pdnt or Type. <br /> Board or Commission ~l~f,~ ~-~,~dl,,J~f ~/~" ~/~ ~0"~ - ~J ~~~ <br /> Name ~~ ~, ~~ <br /> Fi~t <br /> <br /> HomeAddress ~~ ~1~/~ 5/~ M~~ ~7~' Last <br /> Street C~ Zip <br /> <br /> Do you reSide w,hi, ~es ~ .o ,, yes, how long? ~ ~~ <br /> City Council Ward Neighbo~ood Organization ~ ~ <br /> Home Telephone Day Telephone ~5-/~ <br /> Occupation ~'~~~[ ~U~ Place of Employment ~/~' ~/~y~ <br /> Business Address ~ , <br /> Fax Number (~ applicable) ~-/~ E-Mail (If applicable) ~g~O~H$OH~e.~.,~ <br /> How did you learn of this vacancy? D Newspaper ~Word of mouth ~ Mail D Web Page <br /> Other Source <br /> <br /> OPTIONAL INFORMATION <br /> The Eugene City Counc?l 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 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 /> ~'WhitelEuropean American <br /> <br /> Disability: [] Yes If yes. please describe <br /> <br /> Fluent in languages other than English? [] Yes ~No Which language(s)? <br /> <br />Please compie;u both sides of ~is application App~icauo. for Appointmentto Citizen Advisory Boards and Commissions- Page 1 <br /> Revised September, 2001 - P:~CMO~BCC~CCAPP0109119.wpd <br /> <br /> <br />