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<br />ATTACHMENT C <br /> <br />ApPLICA TION FOR ApPOINTlVIENT TO <br />CITIZEN ADVISORY BOARDS AND COMI\'IISSI()NS <br /> <br /> <br />:: <br /> <br />~:::- <br /> <br />:: : ill; <br /> <br />Name of Board, Commission, or Committee \N h; \0.._\'1\ \.l.,,~____N0..:t\.4.<:o.\ p.., \'e.o.. C\'~.3,._~ P\ed\ n; (\ S <br />CoN\M;tt1e~ <br /> <br />Please print or type <br /> <br />Name <br /> <br />C. \\0.\ \ 0 \-\-E:. <br /> <br />E, <br /> <br />be'-'{\".. <br /> <br />flrsf <br /> <br />Midd1e <br /> <br />I.asf <br /> <br />Home Address <br /> <br />-'31 ?Q\-\-D.'-l("'" S-\-, <br />Sfreef <br /> <br />~.~ \' \(\~~Q~\d <br />City <br /> <br /><1'"1417 <br /> <br />lip <br /> <br />I-Iome Telephone <br /> <br />51..\ \ - q 6 It- \ q q 0 <br /> <br />'i . '!V\\)...,'t - <br />Daytime Telephone b ~:..?P\?_ f'l\'-4_f_n_____k~..1.:_~:?8 d. ,\.1\'\ <br /> <br />DQ you reside within the city limits? <br /> <br />~Yes <br /> <br />UNo <br /> <br />If yes, how long?__m__________ <br /> <br />City Council Ward Neighborhood Orgllniz.aHon __ECQ_~_:Lfj_\~-:Ol\__~(&H_S:_____~~~<')" \-)O~ ~oo J f\':S. n <br />Occu-patiorJPiace of Employment _____h_~__~~_ Co f'1\ M u. f\; ~______c:.o._\\.g,~~____m-':_m0{\g.~____~_~_t_~__'__h_______ <br /> <br />Business Address <br /> <br />Fa1\ number (if applicable) <br /> <br />Email (if applicable) <br /> <br />How did you learn of this vacancy? <br /> <br />o Ne>vspaper <br /> <br />~Word of Mouth <br /> <br />o Mail <br /> <br />o Web page <br /> <br />Other source <br /> <br />NOTE. information consisting o./homf.: addressf.'S and phone numbers may be exempt from disclosure per ORS 192_502(3). <br /> <br />OPTIONAL INFORlrfA TION <br />'i1w Eugene City Council supports diversity and seeks to appoint persons who represf.mt the diversity of the community, By <br />providing the :'r!formation belov,,!, you can help the City Council to know ~f the appointments matd1 the diversity f.?lthe <br />community. Applicants are considered without regard to race~ sex, color, national origin, age. religion, marital status, <br />medical condition, or disability. in some instances, howewr, appointment to certain boards/commissions may be based upon <br />the need to fill specific positions on the boardlcornmL\'.slon. <br /> <br />o Male <br /> <br />~Female <br /> <br />o 18 and under <br /> <br />o 19-25 <br /> <br />o 26-35 <br /> <br />o 36-45 <br /> <br />pl46-55 <br /> <br />a 56-65 <br /> <br />066+ <br /> <br />o African American <br /> <br />o American IndianiAlaskan Native <br /> <br />o AsianlPaeific Island(Sr <br /> <br />q Hispanic <br /> <br />o Middle Eastern <br /> <br />o While/European American <br /> <br />o Multiracia! <br /> <br />Disability? <br /> <br />DYes <br /> <br />riNo <br /> <br />If yes, please describe ________nm..__________n__n <br /> <br />Fluent in language(s) other than English? a Yes <br /> <br />%J. No <br /> <br />If yes, please list __...____m_ <br /> <br />\\Ce:;rvpp09\public\CMO\Bollrd5 ilnd CommissioIl5\2005 BCCapplicalioll.doc <br />