HORENO VALLEY GLERK
City of Moreno Valley 25 AUG 6 PN2:34
City Council Advisory
DECEMBER Boards and Commissions
Membership Application Form
Name: Debora
Home Address:
Moreno Valley, CA 92557
City Council District:
How long have you resided in Moreno Valley? years
ELIGIBILITY
Are you at least 18 years of age? Yes A No O
Are you a registered voter of the City of Moreno Valley? Yes A No D Do you authorize the City to process a criminal background check? Yes A No O
EMPLOYMENT
Employer: Retired
Address:
Position:
VOLUNTEER SERVICE
Lostrutor
Length of Time: 10 Years
1 Revised June 10, 2025
BOARD OR COMMISSION INFORMATION
Board or Commission applying for*:
1o Choice Senior Advisory
2nd Choice
3rd Choice
*If applying for the Accessibility Appeals Board, please indicate which position you are applying for:
Physically Challenged Member Member Experienced in Construction Public Member
*If applying for the Utilities Commission, please indicate which position you are applying for:
Public Member Customer of Moreno Valley Utility
Business Customer of Moreno Valley Utility
Do you currently serve on a City Board or Commission? Yes A No O A. If yes, please list: 1 0r divisor
Have you previously served on a City Board or Commission? Yes No M A. If yes, please list:
Do you have any immediate family members serving on the city council or employed with the City of Moreno Valley? Yes • No Xi
Can you attend evening meetings (6:00 pm - 9:00 pm) at least once or twice a month? Yes $ No D Are there days you cannot attend evening meetings? Yes A No O A. If yes, please list: Thursaa
List any education, training, or special skills you have which may be relevant or of particular benefit to this Board and/or Commission:
Dail involument with seniors
2 Revised June 10, 2025
ACKNOWLEDGEMENT
I acknowledge that I was provided with the attached copy of Legislative Policy #1.10 (City Council Advisory oards and Commissions) and offered an opportunity to ask questions regarding any of its provisions prior t ubmitting this applicatior
CERTIFICATION
1 certify that all statements in this application are true and complete to the best of my knowledge. I understand that any false statements of material fact will subject me to disqualification or dismissal if appointed. 08/05/2025
Print Name/Signature Date
All Applications shall be submitted to the City Clerk's office at Moreno Valley City Hall - located at 14177 Frederick St., Moreno Valley, CA 92553 - during regular office hours (7:30 a.m. to 5:30 p.m., Monday through Thursday, and 7:30 a.m. to 4:30 p.m. Friday). Alternatively, applications may be submitted by mail or electronically via the City Clerk's email [email protected].
Background Check Authorization
As part of the application process for service on a City Advisory Board, a criminal background check will be conducted through the California Department of Justice. Please be advised that you will not be provided with a copy of the criminal background information received from the Department of Justice unless you are deemed ineligible due to a disqualifying criminal conviction.
Attachment: Legislative Policy #1.10 - City Council Advisory Boards and Commissions Revised June 10, 2025