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<br />APPLICATION FOR ApPOINTl\fENT TO <br />CITIZEN ADVISORY BOARDS AND COMMISSIONS <br /> <br />~.""'. <br />., <br /> <br />ilJ 1 <br /> <br />~ "NT! <br /> <br />"'- <br /> <br />Home Address <br /> <br /> <br />Name of Board, Commission, or Committee <br /> <br />Please print or type <br />Name <br /> <br />Home Telephone <br /> <br />tY({f.. 1Lf 1..~ I ([ ~ \ <br />......mn. .' n........n...n.n......__..f:1..m...."-........ <br /> <br />Daytime Telephone <br /> <br />Do you reside within !he dly limits'? <br /> <br />o Yes <br /> <br />~No <br /> <br />{fyes, how long? <br /> <br />City Council Ward <br /> <br />Neighborhood Orgomiz.ation <br /> <br />Occupation/Place of Employment <br /> <br /> <br />Business Address <br /> <br />Fax number (if applicable) <br /> <br />Email (if apphcable) <br /> <br />How did YOll learn of this vacancy? <br /> <br />}4.Newspaper <br /> <br />J.( Word of Mouth <br /> <br />o Mail <br /> <br />o Wdl page <br /> <br />Other source <br /> <br />NOTE: Information consisting qfhome addresses and phone numbers may be exempt from disclosure per ORS 192.502(3), <br /> <br />OP110NAL INFOR!UA TION <br />The Eugene City Council supports diversity and seeks to appoint persons who represmt the diversity of the community. By <br />providing the information belilw, you can help the City Council to know if th.: appointments match the diversity of the <br />commtmity. Applicants are considered without regard to race, sex, color, national origin, age, religion, marital status, <br />medical condilion. or disability. In some instances, however, appointment to certain boards/commissions may be based upon <br />the need tojm spect/ic position~ on the board.lcommission. <br /> <br />o Male <br /> <br />JU.Femak <br />Cl19-25 <br /> <br />Cl 26-35 <br /> <br />o 36-45 <br /> <br />o 46-55 <br /> <br />J( 56-65 <br /> <br />066+ <br /> <br />o 18 and tmder <br /> <br />o African American <br /> <br />o American Jndian/AlaskanNative <br /> <br />o Asian/Pacific Is[al'!d~r . . Q . Hisp~nk <br /> <br />o Middle Eastern <br /> <br />;tl WhitelElJropean American <br /> <br />o Multiracial <br /> <br />Disability? <br /> <br />o Yes <br /> <br />ONo <br /> <br />If ves nlease describe <br />.., J. __________.__~.____~_________~___.___._.__._._._.._._._............. <br /> <br />Fluent in language(s) other than English? 0 Yes <br /> <br />RNo <br /> <br />Jf yes, please list <br /> <br />\\Cesnpp()9\puhiic\CMO\Ho<mj~ and Commissinns\2005 BCCapp!kalion.doc <br />