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: