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Clty Cterk's Offrc€
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Commission/Commi
lnldels
Application for Appointment or Reappointment
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(This is a Public Record Subject to Disclosure)
Name of Com mission/Com m ittee/Boa rd i-iet n., nrr, ' !>glr c,, (a.,rtnr -
Appolntment X Rea PPointment
C
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Name of Applica nt C.t
Residence Street Address
tmail nddress
t- .r, \t-rt^q_
City i ,.tt.vr<o., zip(i'5?*r3
7ip
Phone (home)----'- {cell
Length of time at residence
E m ployer'iVt C ? C
Expe rience or Specia I Know edge Perta in ing to Area of lnterest ti te Lr {C ,J ,'5
Employment Expe rience
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Organization, Cornmunity and/or Public Service Experience c! \)
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Education (high school, coliege, trade school or training) Note: There ls no sp ecific educational requirement
U.r '; lL-rDo you have any financial or professional interest or assoc;ation related to this position? -Yes
X ruo
lf yes, please expla in
rx n
(wo rk )
2 3
When are you available to attend this commission/com m ittee/boa rd regular and/or special meetings? .-x\;ril
-
I1 --.! !.r !!.-j .^!^,^^-^. ii irt:c icrcitsiiLc'5 v'vrLir rereiiiiUite iiuiitOer 5 t. \)r-\,.l.i P-\ etr{- Prrone
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A resume containing other pertinent information about yourself would be helpful to the City Council in eva luating your appiication (Optional).
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I Ce!'t,+v Lhat the statpman'( mrda hv ao in thi< rn.l;."ri^n 1r^ r.!,. ^^mh!a+6 .^,..1 .^'r-.r r^ +h- LU iii- !<>L Ui i i,' knowledge and belief. i understand that statements made are subject to verification and that any misrepresentation, I-r,,1 ^- .+j(.'^- -{ -it..;., .-.+. n^., -^-i,r+ i^ -!^-i-t ^, . oL!r, Lo y, -^-^:-r- c5i,r,t ri. Lrtsr iidi ui dfjijuiiriiiieitLl iedppoiitiilteFL I hereby authorize representatives ofthe City of Patterson to contact organizations {including employers and schools) and individuals listed, for the purpose of establishing or verifying my qualifications and work history in connection \,vith this application. I understand and acknowledge that such information will be used confidentialh/ and for the purpose of appointment/reappointment decisions only.
I understand and hereby acceDt that if the City Council of the City of Patterson appoints/reappoints me to a City of Patterson Com rnission/com mittee/Board, lwill serve without oav and will be sub.iect to the filings of the Fa jr political Practices Commisstan lstatement ol Economic lnterest, Form 7OO\. I herebrT further understand and accept that per City OrCinance No.718, if lam a ppointe d/rea ppointed, I will be required to pass a Department ofJustice (DOJ) fingerprint (background) test.
Date Signature t-arr*,,^,r'...,. 5o,*.*,-,
File this application with The City Clerk of the City of Patterson P.C. Box 667
1 Plaza, 2rrd Floor
Patterson, CA 95363
'y'/eb Site www.ci. patterson.ca.us Emaii cie rk cl tterson.ca Direct No. (209) 895-8014
{The City Clerk's Office will keep your appJication on file for one (1) year from the date stamped received) Commission/Commt BB
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Application for Appointment or Reappointment
(This is a Public Record Sub.ject to Disclosure)
€lty Clerk's Office
ps6pscetwd i-3U-&3
AlA
S 1<gO-tl \/r\ Name of Com m ission/Com m ittee/Boa rd 5 E,'t ro Name of Applica nt
Reslde nce Street Address
Mailing Acid ress
Email Add ress
Phone {hom (work)
$fltiaot time at residence / D k Ffi R g
City lip
City r-i" A- 7ip
9;3e=
V€>tL,L
Employer :f
Experience or Special Knowledge Pertalning to Area of lnterest f
'f/,<
Emp yment Expe rience
Ac-ro
lo ie
Orga n ization, Comm unity a nd/or Pu blic Service Expe rien ce u-S F€I< qc*Z't o
Education (high school, college, trade schooi or training) Noter There ls no speclfic educationa requirement tl22t"0 //1 or< Q*LL/]68 Do you have any financial or professional interest or association related to this position? -Ves
X ruo
lf yes, p lea se expla in
l*
-
Appointment X Rea PPointment
When are you available to attend this corrr rrrission/comm ittee/boa rd reguiar and/or speciai meetings? vvi(,'LEreprullE l,u, r uc,5
1 o Fo
2 3
Phone
Phone
Phone
A resume containing other pertinent information about yourself would be helpful to the CitV Council in eva luating your application (Optionai).
I rprtif\/ th.rt thp ct:tpmont< m:da hv mo in thi< r^hli.,ti^h ).^ tttt6 .^m-.t6td 1-A.^rt^.r r^ rh- ha"+ ^f -.. rv !rrr wLrr vr r.r y knowledge and belief. I understand that statements made are subject to verification and that any misrepresentation, l.-,,A ^. -*,"",^^ ^! --+^,;-r 'otL J 'r'oy wr dppL,ri r rErrr/rcdppur'rLr c,rr.
I hereby authorize representatives of the City of Patte!'son to contact organizations (,ncluding employers and schools) and individuals listed, for the purpose of establishing or verifying my qualifications and work history in connection with this application. I understand and acknowledge that such information will be used confidentially and fcr. the pur-pose of appointment/reappointment decisions only.
I understand and he!'eby acceot that if the City Council of the City of patterson appoints,i reappcints rne to a City of Patterson Com mission,/Com nrittee/Board, I will serve without pav and wrll be subject to the fi{ings of the Fair political Practices Commisston lstdtement of Economic lnterest, Form 7OO). lherebli further understand and accept that per City OrCinance No. 718, if I am a ppointed/rea ppo inted, I will be required to pass a Department of justice iDOj) fingerprint (background) test.
D ate 5ig natu r
File this appiication with The City Clerk of the City of Patterson P.O. Box 667
'1, Plaza,2!tC Floor
Patterson, CA 95363
vvcu J]le www.Ll atterson.ca.us Emaii [email protected] ,CA.US Direct No. (209) 895 8014
(The City Clerk's office will keep your application on file for one (1) year from the date stamped received) A DDI !'ATI'1I\I
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