The City of South San Francisco
Office of the City Clerk
400 Grand Avenue
South San Francisco, CA 94080
(650) 877-8518 (fax) (650) 829-6641
CALIFORNIA
Application for Boards and Commissions
APPLYING FOR (more than one may be checked)
Bicycle and Colma Creek Flood Conference Center Conference Center Pedestrian Authority Business Authority Community
Zone Advisory
Advisory Committee* Representative Representative
Committee
Conference Center Cultural Arts Housing Authority Housing Authority Authority Hotel Commission Tenant Commission
Representative
Library Board Measure W Citizens' Parking Place Parks & Recreation Oversight Committee Commission Commission
Personnel Board Planning Commission San Mateo County SSF General Plan Mosquito And Vector 2040 Community
Control District* Advisory Committee
Traffic Safety Youth Commission
Commission
*County Boards and Commissions
Are you interested in participating in the Citizen's Academy? Yes No.
PERSONAL INFORMATION
Name (last, first, middle)
Sath San Francisco, California 94080
Address (number, street, and apartment number) City, State and Zip Code Telephone number Cell phone/alternative contact number E-mail address If you selected more than one Board/Commission/Committee of interest, please rank your preferences here, starting with your first choice.
How many years have you been a resident of South San Francisco? 14 Have you attended any meetings of the commission/board for which you are applying? Yes No If yes, which ones: 07/04/2022
BPAC
Are you a resident of South San Francisco? Yes
If no, are you employed in South San Francisco? Yes
Number of hours employed in South San Francisco:
Housing Authority Tenant Commission No I
Are you a resident of the Housing Authority? Yes
Youth Commission - (Ages 14 to 22)
f not a resident of South San Francisco, are you a student of SSFUSD? Ye Current school: South Santranusco High &boo
Conference Center Authority Hotel Representative
Which hotel within the City of South San Francisco are you representing? South San Francisco General Plan 2040 Community Advisory Committee What is your District of Residency? 5
Click here to locate your District.
Why do you want to be a member of a Board/Commission/Committee? What do you feel you could contribute? I would What is your vision for growth in South San Francisco? I want to be able to achieve higher college eaucation. And give back to my community
Are you currently receiving any form of compensation from the City for work performed? 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. currently attenain Soutn San Francisco HighSchool
Name and location of college/university/technical or trade school Degrees received Also, altonded skijlıne Middle College at Skyline College 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? I'm involued as a volunteer in our communlty group, Friends. of Old Town.
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. 3 months Cricket wireless Oustomer senice
Attending ustmes, selingphones, wif use etc, computer cosing res Dates employed Employer Position
Duties
I certify that, to the best of my knowledge, all statements in this application are complete and true. I agree and understand that any mis- statement of material fact will cause me to forfeit all rights to appointment to a Commission, Board, or Committee with the City of South 07/17/2022
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