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A PLPCATMN FOR REAPPOCNTMEi NT TO COTY <br /> Ells ADVQ SORY BOARD/COMMMON <br /> �- <br /> River - <br /> Reappointment to: <br /> 73065 Clrcana I'arkwa) <br /> 743.635.1004 <br /> APPLICANT INFORMATION <br /> Name: City of Residence: 4 / e ojer - <br /> Occupation: Employer: <br /> Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br /> board/commission for which you are seeking reappointment. <br /> ACv'1f�Ql�- � q• .7 w n � � ,52.1t�r ���(3.1�8�T.A��?-'�-�_RP� �� .J4�a. _�Q�,�_ • <br /> Relevant Experience: Please describe your educational, professional, civic, or community <br /> participation,which may be relevant in serving on this board/ ssion. <br /> co <br /> Attendance: Are your aware of the importance of regular meeting attendance including the time <br /> commitment involved in pteparing for meetings, and do you feel you have the time available to be <br /> an active participant? es ❑ No <br /> a , <br /> Comments: <br /> Conflict of Interest is defined as the participation in any activity,recommended action, or decision <br /> from which the individual has or could have the potential to receive personal gain,whether it be <br /> direct or indizec%. (See attaclacd "Conflict of Iritcrest" Ordinance) <br /> In accordance with this definition, do you have any legal or equitable interest in anti usiness, <br /> however organized,which could be construed as a conflict of interest? ❑ Yes UkNo <br /> If yes, provide deta' on a separate 12icce of paper. <br /> A lira 'i ature ate <br /> Applications will be kept on file for one year,after that time, a new application must be filed. <br /> OFFICE USE ONLY <br /> Council Meeting Date: <br /> ❑ Reappointed <br /> Term Expires: <br /> ❑ Not Reappointed <br />