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· '-.2 <br />APPLICATION FOR APPO II TMENT TO MA <br />CITIZEN VISORY BO DS AND COMMISSIONS - <br />Please Pdnt..or Type, <br /> <br />Board or Commission ~ ~ ~ ~ ~ ~ ~ / = ~ <br /> <br /> First Middle Last <br /> <br /> ~met ~ ' City / Zip <br /> <br />DO you reside within the Ci~ limits? ~ Yes ~ No ,If yes, how long? <br /> <br />Ci~ Council Ward Neighborhood Organization <br />Home Telephone ~ ~ ~ o7.~ ~ ~ Day Telephone ~ ~ <br />Occupation ~~ ~ ~ ~ m ~ Au ~ ~ Place of Employment ~ <br /> <br />Business Address <br />Fax Number (if appli~ble) ~-Mail ~ applic~ ~ <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 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 />~I~ 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 />t~ White/European American <br /> <br /> Disability: ~Yes [] No If yes, please describe <br /> <br /> Fluent in languages other than English? [] Yes ~ No Which language(s)? <br /> <br /> Please complete both sides of this application - Applica~-n for Al:lE~ment to Citize~1~dviso~ Boar~s and Col~missions-~ge~l <br /> Revised September, 2001 - H:\Boards Committees Commissions~Bcc\BCCAPP0109119.wpd <br /> <br /> <br />