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<br />f <br /> <br />\\ <br /> <br />, <br /> <br />APPLICATION FOR APPOINTMENT TO <br />CITIZEN ADVISORY BOARDS AND COMMISSIONS <br /> <br />LWP <br />JUN 2 9 2005 <br /> <br /> <br />Please Print or Type. ~ Mv'~~ <br />Board or Commission f?(iyr~ erst" ~ <br />Name ~./'td tJr ~ <br /> First Middle Last <br />Home Address 6!O tAl I~ ~/1J ~~. oK 17~() I <br /> Street City Zip <br /> <br />Do you reside within the City limits? <br /> <br />I <br /> <br />Home Telephone )if { - 'FrY -If b r 0 Day Telephone <br /> <br />Occupation Ctsr p nr~ ~i1'tc/h,! c~ S Place of Employment <br />Business Address (1; 0 Wrl{dhf Creel< ~e o~ <br /> <br />~es ONo <br /> <br />~:~/c.e .( - t7 _'tJ'- <br /> <br />Neighborhood Organization J;,..Il-J./"'V <br />~~/-n-f- "lIra <br /> <br />If yes, how long? <br /> <br />City Council Ward <br /> <br /> <br />o Newspaper <br /> <br />~all (If applicable) <br />~Word of mouth <br /> <br />1 () <br />~"'lfotl)J,6~ fJ~a"'l# Uwt. <br />OMan OWeb Page <br /> <br />Fax Number (If applicable) <br />How did you learn of this vacancy? <br /> <br />Other Source <br /> <br />OPTIONAL INFORMA TION <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 rece, 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/commlsslon.- <br /> <br />Please check the applicable boxes: <br /> <br />):( Male <br /> <br />o Female <br /> <br />o 18 and Under <br /> <br />o 19 - 25 <br /> <br />o 26 - 35 <br /> <br />;'(36 - 45 <br /> <br />o 46 - 55 <br /> <br />o 56 - 65 <br /> <br />o 66 and above <br /> <br />o African American 0 American Indian/Alaskan Native <br />o Hispanic 0 Middle Eastern <br />o White/European American <br /> <br />XASlanlPaClflc Islander <br />o Multiracial <br /> <br />DYes <br /> <br />){ No <br /> <br />If yes, please describe <br /> <br />DIsability: <br /> <br />Fluent in languages other than English? <br /> <br />Yes <br /> <br />o No Which Ianguage(s)? <br /> <br />10~ <br /> <br /> <br />Please complete both sides of this application <br /> <br />ApplIcatfon for Ippolntm8nllo CllIzen AIMaory Iloarde and CollTl1laalon.. Pege 1 <br />Revised Seplsmber, 3101 . P:\CM:>\BCc\BOOAPP0109119.wpd <br />