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<br />~. <br />" <br /> <br />.41J .., , <br />s'~p, in 05 05: 1 Up PPHSSQ Adm i n 541 342 60B8 <br />t <br />'~ / <br />'~l\~~~ <br /><Vi:' .~~ <br />ApPLICATION FOR APPOINTMENT TO St'P Y4f4 <br />CITIZENADVISORXBOARDS AND COMMISSIONS <br /> <br />p,Z <br /> <br />;g'; <br /> <br />,1 <br /> <br />- <br /> <br /> <br />~-~ <br /> <br />:~ <br /> <br />-::::: <br /> <br />Name <br /> <br />RYo!:: 0 <br />Ftrst <br /> <br />, --.7Li~/7'ASHL <br />Lan <br />!?RO/Jf)t1/dfJ AfJrJ cClf8Y..;E- m" 7/!.t/-o / <br />Of.)> Zip <br /> <br />Mfddk <br /> <br />Hom.e Address <br /> <br />~. SZff s16z. ~tl <br />(~_)(4?q;:-'6!:'(S- _ <br /> <br />Daytime Telephone C~L//.J_.)>;!.~ -- 6 () yf..c!- eK/-;s b <br /> <br />Home Telephone <br /> <br />/....- <br /> <br />Do you r~side within the city Hmjt.~? ~.- Yes <br /> <br />QNo <br /> <br />Jfyes, how long'? .................. <br /> <br />a~..~__...__---:-.,......_ <br /> <br />CkyCmmcilWard . '-"-~ . .. . Neighborlwodiliganlzanon ~~-~~{4? .. <br />O,.upatimVPJac. of Employment ffld/;*rr~drv_,l. C~ (' . ad;eL'?e&-J <br />Business Address d6~----Gx_..1.Q~~__M....~ ('0 t..j.... $A5je.~fi?t~~-I <br />Pax numb" (if 'PPlkabl.)~_ - t?oaJP ._._ Email (if applicable) 1Jj.!2i;J2",f) f!lJh.~ <Xl-; <br />I rcsr::rtt:1~"''V1,e$ <br />How did YO'l.11eartJ of this vacancy? a Newspaper ~(Inl of Mouth Q Mail Q Web page;;~'1 <br />UYt-'1 <br /> <br />Other sj)Ul'ce <br /> <br />~"'.~sn.._.____.. <br /> <br />a..~~~.___~.__~ <br /> <br />NOTE: JrifOrmation consisting of home addresses r.mdphone numbers may be e.xemptfi'om -disclosure per ORS 192,502(3), <br /> <br />OPTIONAL INFORMATION <br />Th.~ EugeneCity Counctl supports diversity and seek.~ to appoi'ntpersons wilD represent the diversity of tIle community, B,Y' <br />providu'lg the i11fOrmation heIoH', you ccm he/pIne City Council to know fjtheappolntrriems match the diversityofthe <br />COfllmw'lity, Applicants are considered without regard to race, .rei, color, nationa.l origin, age, religion, marital status, <br />medical condttton,or disability, In some tnstance.'t, however, appointment (0 certain boards/commissions mtry be based upon <br />the need to fill spec!tw pofJtiop.s on the board/commission. . <br />'" <br /> <br />o Male ~ Pemale <br /> <br />o 18 and under <br /> <br />0(19y25 <br /> <br />Q 26<~5 <br /> <br />Q 36-45 <br /> <br />Q 46-55 <br /> <br />Q 56-65 <br /> <br />Q66+ <br /> <br /> <br />Disability? <br /> <br />o Yes <br /> <br />~o <br /> <br />If yes, please describe _".... <br />"'..... <br /> <br />"Yes ONo IfYes,P.....li"50f~___ <br /> <br />..u___........_.______. <br /> <br />n.---....-......._~.....___............a~. <br /> <br />Fluent in language(s) other than English? <br /> <br />\~(~~~rv,{Ul.\:~n.\'n",v.c('Al:' (t1'\~'\"'io"""'~~""'I..p.r..,.".,,....,:~~.............\D...."JM<:nr1.r....-....,,~..........,.,.~..... ""..... <br />