The City of South San Francisco
Office of the City Clerk
400 Grand Avenue
South San Francisco, CA 94080
(650) 877-8518
1 BOARDS AND COMMISSIONS APPLICATION
APPLYING FOR (more than one may be selected)
Bicycle and Pedestrian Advisory Committee*
*Must be a resident of/or employed in South San Francisco Conference Center Authority -Business Representative
*Must represent a Business in South San Francisco Business Name: _______________________________ Conference Center Authority -Community Representative
Conference Center Authority -Hotel Representative*
*Must represent a Hotel in South San Francisco Hotel Name: _________________________________ Cultural Arts Commission
Equity and Public Safety Commission
Housing Authority
Housing Authority Tenant Commission*
*Must be a resident of the Housing Authority
Library Board
Measure W Citizens’ Oversight Committee
Parking Place Commission
Parks & Recreation Commission
Planning Commission
Traffic Safety Commission
APPLICANT INFORMATION
Full Name:
Last First M.I.
Address:
Street Address Apartment/Unit #
City State ZIP Code
Telephone: Email:
The City of South San Francisco
Office of the City Clerk
400 Grand Avenue
South San Francisco, CA 94080
(650) 877-8518
2 SUPPLEMENTAL QUESTIONNAIRE
Why are you interested in serving as a Boards and Commissions member? What do you feel you could contribute?
What qualifies you for this appointment?
What is your vision for growth in South San Francisco?
The City of South San Francisco
Office of the City Clerk
400 Grand Avenue
South San Francisco, CA 94080
(650) 877-8518
3 SUPPLEMENTAL QUESTIONNAIRE
What community activities are you presently involved in, or have been in the past? 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, Boards, Commissions, or Committees or are otherwise employed by the City of South San Francisco? YES NO
Name: Position: Relationship:
WORK EXPERIENCE
Employer: City:
Job Title: From: To:
Responsibilities:
Employer: City:
Job Title: From: To:
Responsibilities:
The City of South San Francisco
Office of the City Clerk
400 Grand Avenue
South San Francisco, CA 94080
(650) 877-8518
4 EDUCATION
School: City:
From: To: Degree:
School: City:
From: To: Degree:
DISCLAIMER AND SIGNATURE
Signature: Date:
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 San Francisco.
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).
OFFICIAL USE ONLY
Submission Date: Received By: