Laserfiche WebLink
APPLICATION FOR APPOINTMENT TO <br /> CITIZEN ADVISORY BOARDS AND COMMISSIONS <br /> IIIII I ' <br /> Please Print or Type. <br /> Board or Commission ~'~",.~\ ~,;L~'~I~..~ (~cEt['L.*J'y~ ,/~%. C.. PC <br /> <br /> First MF~dle Last <br /> <br /> Strut ~ ' J <br /> Do you reside within the City limits? ~ Yes ~ No If yes, how long? ~0 <br /> <br /> Ci~ Council Ward Neighborhood Organization <br /> Home Telephone ~ ~' ~O Day Telephone z <br /> <br /> O~upation ~ em ~¢ Place of Employment <br /> Business Address L~ - ~~ '~ ~. <br /> <br /> Fax Number (if applicable) E-Mail (If appti~ble) <br /> How did you learn of this vacancy? D Newspaper ~ord of mouth ~ Mail ~Web Page <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 fill specific posffions on the board/commission. <br /> <br /> Please check the applicable boxes: <br /> <br /> Male ~-"~, Female <br /> <br /> [] <br /> and <br /> Under <br /> 19 - 25 [] 26 - 35 [] 36 - 45 ,,.[~46 - 55 <br /> <br /> [] 56 - 65 [] 66 and above <br /> <br /> [] African American [] American Indian/Alaskan Native [] Asian/Pacific Islander <br /> [] Hispanic [] Middle Eastern [] Multiracial <br />"'~ White/European American <br /> <br /> Disability: [] Yes ~ No If yes, please describe <br /> <br /> Fluent in languages other than English? [] Yes ~Y' No Which language(s)? <br /> <br /> Please complete both sides of this application Aopli~ation for Appointment to Citizen Advisory Bol~ds al3d CorrlFitssio~ls. Page 1 <br /> ReviSed September, 2001 - P:;CMO\BCC',BCCAPP0109119.w~d <br /> <br /> <br />