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APPLICATION FOR APPOINTMENT T <br />CITIZEN ADVISORY BOARDS AND COMMISSIONS <br /> _ b I II '1 I I II <br />Please Pdnt or T~. <br /> <br /> F i~t M~ Last <br /> Stol I C~ Zip <br /> <br /> reside with~ [~es ~ No If yes, how long? <br /> Do <br /> you <br /> <br /> Ci~ Counci~ard ~ ~ ~ Neigh~ O~ <br /> Horne Telephone __ ~ ~ Z - ~ ~ Day Telephone <br /> <br /> Fax Number (E applicable) - E-Mail (If appli~ble) <br /> How did you learn of this v~ancV~ ~e~pa~r ~'ord of mouth UMaii OWeb Page <br /> <br /> O~er 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 ff the appointments match the diversity of the <br /> community. Applicants are considered without regard to race, sex, color, national origin, age, religion, marital status, medic~t <br /> condition, or disability, in some instances, however, appointment to certain boards/commissions may be based upon the <br /> .need to ill! specific positions on the boerd/commiss/on. <br /> <br /> Please cheCk the applicable boxes: <br /> <br /> [] Mate _~_~. Female <br /> I-! 18 ~nd Under [] 19 - 25 [] 26 - 35 [] 36 - 45 ~[46 - 55 <br /> r_'] 56-. 65 [] 66 and above <br /> <br /> [] African Ame[ican [] American indian/Alaskan Native ~[Asian/Pacific islander <br /> [] Hispanic [] Middle Eastern E] Multiracial <br /> E} White/European American <br /> <br /> Disability: L-J Yes ~ No If 'yes, please describe <br /> <br /> Fluent in lan<juages other than English? ~ Yes [] No Which language(s)? <br /> <br /> Please complete both .~ides of this epplic'aEon l~,,c~v,~, ~ ,~c.p~,m-,en~ ~ C,~'~ <br /> <br /> <br />