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. · , ' LWP ATTACHMENT B <br /> APPLICATION FOR APPOINTMENT TO I',~::~'~ 2; <br /> <br /> Street ' ~ ' " I <br /> C~y ~ Z~p <br /> <br /> City Council Ward <br /> %1 qqV Or,..,z.t, on <br /> Occ~,a~,on ~ ~.:-_. ~.~.eC ,. <br /> ._ _, - _ <br /> Fax Num bet (if applicable, E-Mail (If applicable, ~-- a~ ~ <br /> .o~ ~ ~ou ~ar. o~,~ v.~nc~V D"~w~.~.~r D~or~ o~ ~outh D~a~ D~e~ "aoe / <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 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 fi//specific positions on the board/commission. <br /> <br /> Please check the applicable boxes: <br /> <br /> [] Male ___~__~Fe m ale <br /> [] 18 and Under [] 19 - 25 ,~6- 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 />,,,,'~ hite/E uropea,n American <br /> <br /> Disability: FI. Yes If yes, please describe <br /> <br /> Fluent in languages other than English? [] Yes yNo Which language(s)? <br /> <br /> Please oornplet'e both sides of ff~is application Application for ,~ppolntment lo Citizen Advisory Boards and Commissions- Page <br /> <br /> Revised September, 3{)01 · P:[CMO~BCCtBCCAPP0109119.wlxl <br /> <br /> <br />