Laserfiche WebLink
<br />~t"\k~ <br />81' c~tCEIf/I!O <br />ApPLICATION FOR ApPOINTMENT TO S& ~"'1~ <br />CITIZEN ADVISORVBOARDSAND CO,MMISSIONS. <br /> <br />9/s1tJY:J <br /> <br />~/CS- <br /> <br />ATTACHMENT B <br /> <br /> <br />Name of Board, Commis~ion, or CommitteeJ'~\\4~t~lS'iof\ <br /> <br />Please print or type <br />Name <br /> <br />:So~n <br /> <br />First <br /> <br />_.~~..rl\6 <br />Aliddle <br /> <br />\1t1.r~ <br /> <br />Last <br /> <br />Home Address <br /> <br />\1..'!,~t> ~. '2.()~ I\".~ CityEJ,~ , otL <br />Stree I <br /> <br /><::\, t..ft)3 <br /> <br />~....~--...--..- <br /> <br />Zip <br /> <br />Home Telephone <br /> <br />S'-\\-'51.0 · ~SC03. <br /> <br />Daytime ,Telephone <br /> <br />Do you reside \vithin the city limits? ,J{Yes <br /> <br />ONo <br /> <br />If yes.. how long? _ \ 1.. ~ b4f'6 <br /> <br />City Council Ward <br /> <br />?> <br /> <br />Neighborhood Organization __~ \J tJ 1\ _..... <br /> <br />. OccupationIPlace of Employment ~'- \~ t.M~~~ <br />. '1..~,-\<l} W\ \\t..~",,-+N..6}. ~OS~"" Otl. ~1~t)3 <br />Email (if applicable) ~C\~ \\qr:.t..~ ~A~ \" Go"" <br /> <br />Business Address <br /> <br />.Fax number (if applicable) sq\- '-l3 '-1~ C, ~.O l <br /> <br />l-Iow did you learn of this vacancy? <br /> <br />o Ne\vspaper <br /> <br />)l\\lord of Mouth <br /> <br />o tvlaiJ <br /> <br />o Web page <br /> <br />Other source <br /> <br />lvrOTE: Information consisting afhome addresses and phone numbers may be exenrpt from disclosure per ORS 192.502(3). <br /> <br />OPTIONAL INFOKMA TION <br />The Eugene City Council supports diversity and seeks to appoint persons lvho represent the diversity of the cornmunity. By <br />providing the information beiolv, you can help the City C~ouncil to .knout if the appointments m.atch the diversity of the <br />community. Applicants are considered lvithoul regard to race~ sex, color, national origin, age, religion, marital slatust <br />medical condition, or disability. In some instances, however, appo!nlment to certain boards/comlnissions may be based upon <br />the. need toftll specific positions on the board/commission. <br /> <br />JAMale <br /> <br />o Female <br /> <br />o .18 and under <br /> <br />o 19-25 ){26-35 <br /> <br />(J 36-45 <br /> <br />o 46-55 <br /> <br />a 56..65 <br /> <br />.066.'+ <br /> <br />o African A.merican <br /> <br />(J. Ame.nean In<UanlAfaskan.Native <br /> <br />1]). .Asian/P~clfic Islander <br /> <br />Q. Bispanie <br /> <br />o Middle Eastern <br /> <br />)(VlhiteIRufopeanAmerican <br /> <br />o !v:fultiracial <br /> <br />Disability? <br /> <br />DYes <br /> <br />..wNo <br /> <br />I f yes, please describe <br /> <br />Fluent in language( s) other than English? ~ Yes <br /> <br />DNa <br /> <br />If yes, please list '"L '" fS COn~ ~~,t, <br /> <br />\\Cesrvpp09\public\CMO\Boards and Commissions\~OO5 BCCapplication.doc <br />