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FF?OM <br />~soes oro~ ~.::~;.. , <br />~~s:~aa~ooo. <br />APPLICATION FOR REAPPOINTMENT TO CITY <br />ADVI50RY BOARD/COMMISSION <br />FAX N0. :7632413715 Jan. 14 2011 04:08PM P2 <br />Reappointment to: ~~GY Ci-ry ~~reM~S`~-o~5 <br />APPLICAIV'I' INFORMATION <br />Name: ~~ ~ ~_ ~`T'A~.A City of Residence: fl~o~~ <br />Occupation. ~~ }~ _ ,_ Employer: ~~~_ ~- ~~~1~ <br />Statement of Interest: Please state briefly why you are interested in contiszuing to serve on the <br />b~o+ard/commission fo/~r which you a1te seeking rea pointment_ <br />~~ ~ S~ IJYLT <br />Comments: <br />Conflict of Interest is defined as the participation in any activity, recommended action, or dec~sioz7. <br />from which the individual has or could have the potezxtial to receive personal gain, whether xt be <br />direct oz indirect (See attached "Conflict of Interest" Ordinance) <br />In accordance with this definition, do you have any legs]. oz equitable interest in any business, <br />however o b4avi2eci, which could be construed as a conflict of interest? ^ 'Yes ^ No <br />If yes, provide details on ~a se aratE -ece of a er. <br />'/~~/~~ <br />Date <br />be kept oa fIe fot one year; Frfter that trine, s newapplicatior! must be &led. <br />OFFICE USE ONLY <br />Council Meeting Date: <br />^ Reappointed <br />Term Ea-pines: _ <br />^ Not Reappointed <br />Attendance: Are pour aware of the importance of regulaz meeting attendance including the time <br />commitment involved in preparing for meetings, and do you £eel you have the time available to be <br />an active participanL> Yes ^ No <br />ReIe~vant Experieaee: Please describe pour educational, pzofessional, civic, or community ~Oi"`~''° <br />participation, which may be relevant in serving on this board/cotnu11ss1on. <br />