RECEIVED
City of
San Bernardino
BOARDS, COMMISSIONS, & CIZEN ADVISOROUNCIL OFFICEd. For TRADED H 90! COMMITTEES City of San Bernardino
BOARDS), COMMISSIONS), AND/OR CITIZEN ADVISORY COMMITTEE(S) APPLYING FOR:
1. AnimalControl 3.
Commissione
2. Gth wand 4.
LAST NAME FIRST NAME M.I.
Henderson Matine A,
HOME ADDRESS ZiP PHONE
(HOME)
(MOBILE)
EMPLOYER JOB TITLE EMAIL ADDRESS
BUSINESS ADDRESS ZIP BUSINESS PHONE
DATE OF BIRTH
Length of residence in the City of Are you a registered voter of the City Which ward do you reside in? San Bemardino of San Bemardino?
8 Years Yes
2 Months No
Why you want to serve on a city board or commission:
What do you consider to be three (3) major assets that would qualify you for selection to this board, commission, or citizen advisory committee:
Experience or special knowledge pertaining to area(s) of interest:
for my animab+ inject them myself.
He a pageant Are sul am a semen"
Occupational experience:
Professional or technical organization memberships:
Board(s). Commission(s), & Citizen Advisory Committcos) App. Page 2 of 3 Updated: August 29, 2018 Civic or community experience, memberships, or previous public service appointments:
Mu sent Nose New lose is al mu Baptist Chuck Sot
resent water comesin
How would you classify yourself? (Optional)
American Indian/Alaskan Native African American/Black Asian Hispanic/Latino Native Hawaiian/Pacific Islander White
Two or more of the above categories
What is your gender? (Optional)
Female Other/Prefer to self-describe
Male
Are you a person with a disability? (Optional
Yes No
sometimes
Applications are screened on the basis of information submitted and may be subject to a Livescan as part of the application process.
The information provided is factual to the best of my knowledge. I understand that I may be required to complete a Statement of Economic Interests Form as required by law, and that I will abide by all the codes, ordinances, and regulations of the City of San Bernardino and the State of Mand march 21-2025
SIGNATURE DATE
Return to: The City of San Bernardino Council Office
alectronically: [email protected]
By Mail: 290 North D Street, San Bernardino, CA 92401
In Person: 290 North D Street, 1st Floor - City Information Center, San Bernardino, CA 92401
*Attach a resume and/or additional information which you feel will assist the Mayor and City Council in their selection.
Board), Commission(s), & Chizen Advisory Committed's) App. Page 3 of 3 Updated: August 29, 2018