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APPLICATION FOR REAPPOINTMENT TO CITY JAN 8 <br /> Oty of ADVISORY BOARD/COMMISSION <br /> ')f *vN= <br /> El aft4�— <br /> . <br /> 1300()-11"Pa,k".) <br /> 761.635.I(HY) r Reappointment to: L"-14A <br /> APPLICANT INEORMATION <br /> Name: of Residence: <br /> Occupation: ct <br /> Flnij)lo'�er: 4 <br /> )r <br /> Statement of Interest: Please state briefly why you are interested in contimung to serve on the <br /> board/corntnission for which voLi are seeking reappointment <br /> 1, "5 -1' <br /> .... ...... <br /> Relevant Experience: Please describe your educational, professional, civic, or co,)rninunity <br /> participation, which tnav be relevant in serving on this board/corninissiOn, <br /> c 1, <br /> 4. <br /> rill <br /> Attenda ce: ,'117CIMltawaieo tlicil-iil-)ortince ()fregular iii.eeti.i-igatteiidaiicc '1i-icluditigthe time <br /> con-iiiiiti-tictit i 1117()INed�n preparing for meetings, and do yon feel you have the tilile available to be <br /> an active participant-? P"'"des No <br /> Corrinictits: <br /> Conflict of Interest is defined as the participation in any activity, reconirricrided action, or decislOn <br /> frorn which the individual has or could have the potential to rcccive personal gain, whether it be <br /> direct or indirect. (See attached "Confuct of Interest" Ordinance) <br /> In accordance with this definition, do �'()Lj have: an)- legal or equitable interest in any business, <br /> however or9 anizcd, which could be construed as a conflict of interest? N <br /> Yes o <br /> If ves, provide details on a;,se: carate pdace of t)at)cr. <br /> P scant Signature Date <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 "1\4eefing Date: <br /> Reapl-)ointed <br /> Tcrm Fxpirc.s: <br /> Not Reappointed <br />