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ATTACHMENT C <br /> <br /> APPLICATION FOR APPOINTMENT TO <br /> CITIZEN ADVISORY BOARDS AND COMMISSIONS <br /> IIII BII II · I ' I I <br /> Please Print or Type. <br /> <br /> First Middle <br /> Home ~dress ~ 0 c~. ~ ~,'~;', (L. ' <br /> Strut ~ ~ ty.~' ' ~p , <br /> <br /> DO you reside within the Ci~ [Jm~s? DYes B~" If yes, how long? <br /> Ci~ Council Ward Neighborhood Organization <br /> Home Telephone "~ ~' [ c =~ ~. <br /> · - ~(..2~:>~- DayTetephone <br /> <br /> Business Address g"'~ C"' ~--~ ~ ' , ~/~'~ . ' '" <br /> j ~ ~ , j, <br /> <br /> F~ Number (if applicable) E-Mail (If applicable) <br /> How did you learn of this va~ncy? ~ Newspaper ~ Word of mouth ~ Mail ~Web Page <br /> Other Source '~'¢'~ ' u ~ ~-~-~ [' <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 /> r~'" Male [] Female <br /> <br /> [] 18 and Under [] 19 -25 [] 26 - 35 roi 3'~6 - 45 [] 46 - 55 <br /> [] 56 - 65 [] 66 and above <br /> <br /> [] African American [] American Indian/Alaskan Native [] Asian/Pacific Islander <br /> [] Hi?panic [] Middle Eastern [] Multiracial <br /> J];~hite/European American <br /> <br /> Disability: [] Yes [~/'~o If yes, please descdbe <br /> <br />Fluent in languages other than English? [] Yes []'"~0 Which language(s)? <br /> <br />Please complete both sides of this application A~ouca~on for Appointment to C[tize~ Adviso~ Boards and C~mmlssions. Page 1 <br /> Revised September, 2001 - P:~.CMO~BCC~CCAPP0109119.v43d <br /> <br /> <br />