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13065 0.. IMrkure] <br />963.635,1000 <br />JAN 2 4 2011 <br />APPLICATION FOR REAPPOINTMENT TO CITY <br />ADVISORY BOARD/COMMISSION <br />Reappointment to: _14PL3 ahtl r?P_cr j-.... A `A r`cMiSsra.� <br />APPLICANT INFORMATIOjN <br />Name: AAA l i o le�{f City of Residence: � r k <br />Occupation:' ��o T¢n CSL Employer: <br />Statement of Interest: Please state briefly why you are interested in contin„ino t. Pn, ,,., .n.., <br />Relevant Experience: Please describe your educational, professional, civic, or community <br />participation, wY ich,may be relevant intferving on this board/cnmmicsinn <br />e' <br />04 _4- S LS . u,j kR9C kJ'A �yt�Y�i55 a✓1' w Ci &A Cj��t S caN0. Y1Gv�_ <br />�,l tX.SS i X11 <br />Attendance: Are your aware of the importance of regular meeting attendance including the timen r <br />m <br />comitment involved in preparing for meetings, and do you feel you have the time available to be'aJI rM. <br />an active participant? Yes ❑ No C�-A j <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 ind ect. ;Su ata ped "Conflict of Interest" Ordinance) <br />In accordance with this definition, do you have any legal or equitable interest in an \- business, <br />however organized, which could b onstmed as a conflict of interest? ❑ Ye= '�ANo <br />If yes, pro -ide lc- S _>a a _ i ece of a er. f <br />✓'�11� <br />Applicant Signature Dat ` <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 />3 Not Reappointed <br />