1 OFFICIAL APPLICATION FORM
______________________
City Clerk or Deputy City Clerk
_________________________________
Date
CITY OF PASADENA
APPLICATION FOR APPOINTMENT TO THE CITY COUNCIL, DISTRICT 3 The information contained on this form will be used by the Pasadena City Council to fill a vacancy for the District 3 seat due to the passing of the Honorable Councilmember John J. Kennedy. All applicants must be a resident living in Council District 3, of voting age, and registered to vote in Council District 3 at the time the application is issued by the City Clerk. Applicants are invited to attach additional pages, a copy of your resume, or submit supplemental information which you feel may assist the City Council in its evaluation of your application.
Applicant Name:
Home Address: Home Phone: ( )
Employer: Work Phone: ( )
Work Address: E-mail:
Community Service - List boards, commissions, committees, and organizations on which you are currently serving or have served, offices held, and in what city.
Employment - Title and duties, current and past.
Education – Include professional or vocational licenses or certificates.
ATTACHMENT C
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Personal – Answer “yes” or “no” to the following questions.
1. Have you ever worked for the City of Pasadena? (If yes, please list dates/department) YES NO
2. Are you related to any employee or appointee of the City of Pasadena? (If yes, please YES NO indicate name and relationship)
3. Are you aware that financial disclosure will be required to serve? (e.g. sources of YES NO income, loans and gifts, investments, interests in real property)
4. Rules of law and ethics prohibit members from participating in and voting on matters YES NO in which they may have a direct or indirect financial interest. Are you aware of any potential conflicts of interest which may develop from your occupation or financial holdings in relation to your responsibilities as a member of the City Council, to which you seek appointment? (If yes, please indicate any potential conflicts)
5. Have there been or are there now, any personal or business circumstances which might YES NO reflect adversely on the propriety of your serving as a member of the City Council to which you might be appointed?
6. Are you aware of the time commitment necessary to fulfill the obligations of the YES NO City Council, District 3 seat, to which you seek appointment?
3 Application for Appointment - continued
7. What specifically in your background, training, education, or interests qualifies you as an appointee?
8. What do you see as the objectives and goals of the City Council?
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9. How would you help achieve these objectives and goals? What special qualities would you bring?
Signature: Date:
I hereby certify that the following information is correct to the best of my knowledge.
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Prior to September 8, 2022 at 5:30 p.m., submit original application to: Mark Jomsky, City Clerk 100 N. Garfield Ave., Room S228
Pasadena, CA 91109
Applications not received by the above stated deadline will not be accepted or considered for appointment.