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APPLICATION F DR APP TMENT TO CITIZEN ADVISORY BOARDS COMMISSIONS 8YCi ' ED Please Pdnt or Type. Board or Commission ~u~u ~'5'~_~, Fi~t Middle Last Home Address 1~ g~ L~'~ ~u~ Stmet City Zip Do you reside within the CiN limit~? ' ~ Yes ~ No ,If yes, how long? Ci~ Council Wa . _ ~ Neiohbo~ood Om~ Home Telephone ~qt- 5t5-,~1, DayT~eph°ne '-~~~ - O~upation ~tcW ~[ ~~[~ Place of Employment Business Address Io* ~ 5~ ~F~[u~ ~ ~~ FaxNumber (if applicable) ~q ~ Wz~z~ E-Mail (If applicable) How did you learn of this vacanc~ ~ Newspaper ~Word of mouth ~ Mail ~ Web Page Other SoUrce OPTIONAL INFORMATION The Eugene City Council supports diversity and seeks to appoint persons who represent the diversity of the community. By providing the information below, you can help the City Council to know if the appointments match the diversity of the community. Applicants are considered without regard to race, sex, color, national origin, age, religion, marital status, medical condition, or disability. In some instances, however, appointment to certain boards/commissions may be based upon the need to fill specific positions on the board/commission. Please check the applicable boxes: .~ Male [] Female [] 18 and Under [] 19 - 25 I~ 26 - 35 [] 36 - 45 [] 46 - 55 [] 56 - 65 [] 66 and above [] African American ,[~ American Indian/Alaskan Native [] Asian/Pacific Islander. [] Hispanic [] Middle Eastern [] Multiracial [] White/European American Disability: [] Yes I~ No If yes, please describe Fluent in languages other than English? [] Yes I~ No Which language(s)? P/ease complete both sides of this application Application for Appointment to Citizen Advisory Boards and Commissions. Page 1 Revised September, 2001 - H:\Boards Committees Cornmissions\Boc~EiCCAPP0109119.wpd