City of Moreno Valley MORENO VALLEY CLERK
25 JUL 11 AM11:36
City Council Advisory
DELENBER 1. MA Boards and Commissions
Stam acades Receives
lylembership Application Form
Name: Pauline MovA
Home Address:
Moreno Valley 92555
City Council District:
How long have you resided in Moreno Valley? I
ELIGIBILITY
Are you at least 18 years of age? Yes# No O
Are you a registered voter of the City of Moreno Valley? Yes No O Do you authorize the City to process a criminal background check? Yes # No O
EMPLOYMENT
Employer: Retired
Address:
Position:
VOLUNTEER SERVICE
Name of Organization: Moreno Valley Senior Center Ferra Seniors/ Adaptive Purpose: Teach EsL Zumbat fit
Instructor
Length of Time: 3 his weekly
1 Revised June 10, 2025
BOARD OR COMMISSION INFORMATION
Board or Commission applying for*:
1st Choice Senior Adiusoey Board - Mo Val
2nd Choice
3d 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 M No O A. If yes, please list:_ Senior AdvIsoRy Board
Have you previously served on a City Board or Commission? Yes • No E 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 17
Can you attend evening meetings (6:00 pm - 9:00 pm) at least once or twice a month? Yes • No B Are there days you cannot attend evening meetings? Yes I NO O A. If yes, please list: none, no evening meetings
List any education, training, or special skills you have which may be relevant or of particular benefit to this Board and/or Commission:
2 Revised June 10, 2025
ACKNOWLEDGEMENT
CERTIFICATION
I 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. 1/11/2025
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 3 Revised June 10, 2025