Ciry Clerk's Office
Commission/Comra Bare Reard 4-20-23
CHEAT NO Time 2:30 P.m
Application for Appointment or ReappoihtinentA
AEORPORATED COR
(This is a Public Record Subject to Disclosure)
Name of Commission/Committee/Board H. S. C-
Appointment _Reappointment
Name of Applicant DARWIN DEROSANS
Residence Street Address _ City pAtteRSON CA Zip 2536}
SAME AS A300 E _City.
Mailing Address.
Phone (home). (cell). (work).
_Length of time at residence Z
Email Address
Employer
Experience or Special Knowledge Pertaining to Area of Interest HIVE
Employment Experience
No CuzzenT EmploymenT- fesT pell Bens A
11. SIC.
VOlUNTEER
Organization, Community and/or Public Service Experience ATTHY
Education (high school, college, trade school or training) Do you have any financial or professional interest or association related to this position? _ L _Yes XINO If yes, please explain.
When are you available to attend this commission/committee/board regular and/or special meetings? Avalasle MosT OF TIR TIME
4.5. A. P. - ATters meeties
Please list three references with telephone numbers:
Phone_
Phone
Phone
A resume containing other pertinent information about yourself would be helpful to the City Council in evaluating your application (Optional).
APPLICATION CERTIFICATION: PLEASE READ BELOW BEFORE SIGNING.
I certify that the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief. I understand that statements made are subject to verification and that any misrepresentation, fraud, or omission of material facts may result in denial of appointment/reappointment.
I hereby authorize representatives of the 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 with this application. I understand and acknowledge that such information will be used confidentially and for the purpose of appointment/reappointment decisions only.
I understand and hereby accept that if the City Council of the City of Patterson appoints/reappoints me to a City of Patterson Commission/Committee/Board, I will serve without pay and will be subject to the filings of the Fair Political Practices Commission (Statement of Economic Interest, Form 700). I hereby further understand and accept that per City Ordinance No. 718, if I am appointed/reappointed, I will be required to pass a Department of Justice (DOJ fingerprint (background) test.
one 4/24/23 Dawn Perone
_ Signature.
File this application with: The City Clerk of the City of Patterson P.O. Box 667
1 Plaza, and Floor
Patterson, CA 95363
Web Site www.ci.patterson.ca.us Email [email protected] 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)