South San Francisco General Plan 2040 Community Advisory Committee What is your District of Residency? ____
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Why do you want to be a member of a Board/Commission/Committee? What do you feel you could contribute?
What qualifies you for this appointment?
What is your vision for growth in South San Francisco? ___________________________________________________________________ ________________________________________________________________________________________________________________ Are you currently receiving any form of compensation from the City for work performed? Yes _ No If yes, please explain:
Do you have any relatives serving on Council, Commissions, Boards, and Committees or otherwise employed by the City of South San Francisco? Yes No If yes,
Name Position Relationship
EDUCATION - Please include additional information on separate sheet. ________________________________________________________________________________________________________________ Name and location of college/university/technical or trade school Degrees received ________________________________________________________________________________________________________________
________________________________________________________________________________________________________________ Name and location of college/university/technical or trade school Degrees received ________________________________________________________________________________________________________________
What community activities are you presently involved in, or have been in the past? _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ MISCELLANEOUS - Please include additional information on separate sheet or attach resume.
Military Service: Dates and branch
WORK EXPERIENCE - Please include additional information on separate sheet or attach resume. ________________________________________________________________________________________________________________ Dates employed Employer Position
________________________________________________________________________________________________________________ Duties
________________________________________________________________________________________________________________ Dates employed Employer Position
________________________________________________________________________________________________________________ Duties
I would like to contribute to the safety and well-being of my family and our neighbors. I have experience with management and safety in my previous work with several corportations. Greater communication between neighbors and creating a safe environment for our children to grow up and learn in. N/A N/A City College of San Francisco Drug and Alcohol Certification Studies Substance Abuse Counselor and Rescue Team at San Francisco Neighborhood Aid Center for Homeless with Severe Addictions N/A 2011-2021 Mission Council Dry Zone (DUI) Substance Abuse Counselor ✔ ✔
I certify that, to the best of my knowledge, all statements in this application are complete and true. I agree and understand that any misstatement of material fact will cause me to forfeit all rights to appointment to a Commission, Board, or Committee with the City of South San Francisco.
Signature Date
The interest of the City is served best by actual and regular participation by Board and Commission members. Thus, upon the second absence from a regular meeting within any rolling twelve-month period, a member shall receive a written communication from the Mayor requesting that the member respond to the Mayor with an explanation for said absences within one week of the member’s receipt of the written communication. The Mayor shall report to the City Council the reasons provided for the member’s absences. If the City Council determines that the absences occurred for legitimate reasons, the City Council may excuse both or one of the absences. Members are also encouraged to give advanced notice of their absence from meetings.
Applications are accepted on a continuous basis and will remain valid 1 year from the date of submission. If you are selected to serve on a Board or Commission, you may be required to file an Annual Statement of Economic Interest (FPPC Form 700) and bi-annual Ethics Training (AB1234).
PRINT AND MAIL TO:
CITY OF SOUTH SAN FRANCISCO
Office of the City Clerk
400 Grand Avenue, South San Francisco, CA 94080
For more information, call (650) 877-8518
For official use only Accepted Not Accepted Initials Date 3/7/2022