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<br /> <br />" <br /> <br />~ .;./ <br />w~~~ <br /><V'f'! c\\~ <br /> <br />RE(" <br />BYeI,..? ATTACRMENT C <br />$EP .Si2a05 <br /> <br />~Pf~IC~~I~~c~~~;,~.~~OI~~lStrcT~ <br />CITIZEN'A,DVISORY<BoAlIDS..AND C01VfMl,SSIONS <br /> <br />~-=~ <br /> <br />= ~ <br /> <br /> <br />.: <br /> <br />Name ofBo.rd, Coullnissitm, a. Committee --H~ ~. .~~ <br /> <br />Please print or type <br />Name <br /> <br />_..... ./Vl~.~..._~.. <br /> <br />First <br /> <br />I .I <br />-....-.....~M~\j). )....~___ <br />Last <br /> <br />.----_OJt_..__q '] ~to ,.S- ...___..___ <br />Zip <br /> <br />M~1d!i! <br /> <br />Home Address <br /> <br />JjOd3~~lJ;, f.4tt~'K <br />Street <br /> <br />:~\Je~IJt\ <br />City <br /> <br />Home Telephone i;}j( ,. i113..=- ~ \tf.Q_~____.______ <br />Do you reside within the city limit<;? X Yes Q No <br /> <br />Daytime Telephone _... ~.4'L:--= (11~.__~5 V-t0__~.____ <br /> <br />liYe!, hOWlong'llll ~~~___ <br />,'pM <br /> <br />City Council Wam .'1............ ,.. . .:-c N~jghbO~.O~Org>~.,",iO.~~'~~~ <br />()CCtiP.#OWPI~.otr""PI~.~t ..~- .~ ................-S-" ... .' ... ..i..' · .-~- <br />Business Address __4Qt22)J;~-'::PJ.e " ~t, #- K ___n.~ . I f) R..~.J q 0.f?:~____._____.____ <br />Fax number (if applicable) ---.-.____n.--:..~- __________ Email (if applicable).____.________________________.____ <br /> <br />Ho'.\' did you leam of this vacancy? <br /> <br />o Newspaper <br /> <br />, ~V(!rd of Mouth <br /> <br />a Mail <br /> <br />Q Weh page <br /> <br />Other source <br /> <br />_..........----....-....._.-------.._.._-.._~----....._--.----------...._._-----_..-._--~.._._.._""- <br /> <br />NOTE: Ir;formatton consisting of home addt'e:;~<;es amlphone numbersmq}'.be exemptfromdisclosureper ORS 192.502(3). <br /> <br />OPl'10NALlNJ?QRA1A7;10N <br />The Eugene CityCounqil sypportsdiver:Htyandseeks to (JlifJ~ilttpersons who representihediversityoj'thecormnunity_ By <br />providi'tlgthe information belmt~ you "an help tlte CityCouncUto know!f the. appointmEmts matr:h.the diversIty of the <br />community, Appliccmtsareconsidered with?utregardto rax~i" sex, color, nationatorigin, age'i religion, marital status, <br />medical condition, Or disability. In some instances, however, appointment to certain boar~i~!commisskms may be based upon <br />the needtofillspecftic positions ontlliE board/commission. <br /> <br />(J Male <br /> <br />)(Femaie <br />Q 19-25 <br /> <br />Q 26-35 <br /> <br />a 36-45 A1.,46-55 <br /> <br />Q 56-65 <br /> <br />Q 66 -+ <br /> <br />o 18 and under <br /> <br /> <br />,Disability? <br /> <br />aYes <br /> <br />UNo <br /> <br />Fluent ill ianguage(s) other than English? <br /> <br />"f::A1. T <br />n xes <br />/' \ <br /> <br />If yes, please descrihe ---'''---'-~'--'------------~.__.m._____..___..___...__ <br />V A.. i, ft' <br />If yes, piease list .__ . ~.4~tv::! H\'~\--...(M..___ <br />l <br />/ <br /> <br />uNo <br />