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<br />\;L:i-.t 0 /' <br />~~ ~\,o\r;;~ <br /> <br />ApPLICATION FOR ApPOINTMENT TO Sy' Cel <br />CITIZEN ADVISORY BOARDS AND COMMISSIO~ Y414 <br /> <br />. ~/llIL~ <br /> <br />..- ~p-- <br /> <br /> <br />II <br /> <br />~! ' <br /> <br />Name or Board. Commlsaion. or Committee 'Iltt i \Qt.\} \: OO\J\~ tl\'ti.c.;\ 11.l>,J ?~f\\~~m i \tee <br /> <br />Please print or type <br />Name __ R.Q Se.{k'()'(\-e..- <br />First <br /> <br />c_~~f~_...._.....___._~Vr\Rf\~~ <br />Middh Lan <br /> <br />Home Telephone ., 4- \0- 0 \ \ ~ <br /> <br />~Jvr\'(\ ~~.\~\c;l q~ 411_______________.____ <br />Daytime Telephooe ....., -.{ to - 0 \, \ '3 <br /> <br />Home Addres-,> _.._..\~??m:&___s:Y"r ee. \" <br />Strees <br /> <br />Do you reside within the city limits? 0 Yes <br /> <br />~No <br /> <br />If yes, how long? <br /> <br />,:~r'''~4.;.J <br />:fi\;. <br />" <br /> <br />Ci~' Council Ward -- . <br />... .nn~_..-. . <br /> <br />Ncighoorhood Organi:z.atio!l...._ <br /> <br />~ <br /> <br />Ocalpation/Place of Ernployment r-e- +\ t'€' ~ . ,tve. n-----gp--~.\e. p ~ '3 <br /> <br />BUSIIl(.'$S Address <br /> <br />Fax number (ifappHcubJe) <br /> <br />Email {ifappHcable}c~)v._Cr~.J\KrA.-!)L~PiA.H~..sT. ('-eM <br /> <br />How did you learn of this vacancy'? ~-..:Je\'I'Spaper <br /> <br />Other source <br /> <br />o Word of Mouth <br /> <br />Q Mail <br /> <br />Q Web page <br /> <br />NOTE: lrifonrl(ltion consisting of flryme addresses and phone numbers mt:{Y be exempt from disclosure per OM 192.502(3). <br /> <br />k"-Il.. ""'191'11. <br /> <br />OPTIONAL INFORMATION <br />The Eugene City COllllcil supports diversity and seeks to appoint persom; who represent the diversity of the community. By <br />pro\'idirsg the information below, .wu can help the City COUl1Cil to know if the appointments match the diversity oflhe <br />commWlity, Applicants are considered without regard tQ race, ~ color, national origin. age, religion, marital status, <br />medical c(}fuiitiors, or disability, in some imtances, hqwever, appointment to certain boards/commissions tm{P be based upon <br />tlw need 10 flll specifIC positiom; on the board/commission. <br /> <br />U 18 and und~ <br /> <br />~ernale <br />o 19~25 . a 26--35 Q 36-45 a 46-55 ~6-65 <br /> <br />066+ <br /> <br />a Male <br /> <br />o Afti~!un~g1~.O~IY4iSW~~NaUve 0 ~l$~ <br />.'$l..~~(#;~~. .,"'~t~~~~:... ~~~J. <br /> <br />Disability? ~Yes a No If yes, please deseribe &.o~_~t\:~c k:. So -l,J \ \ \ GC::f-t'.-$ \ C'i'\.4~ ~.~~ <br />Fluent inlanguage(s) other than F..nglish? q Yes .~o Jfyes, please list _.......__.._ <br /> <br />o~c <br /> <br /> <br /> <br /> <br />