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Print Form <br />CITY OF SANTA ANA <br />r~~»° <br />t... ;.w.,I <br />APPLICATION FOR SERVICE "" ` ^ ~' ~'.~ 2. 34 <br />BOARDS /COMMISSIONS /COMMITTEES ; <br />Name (Mr., Mrs. Ms:) ~~.~~%~' ~ ~ ' _ <br />i~ i _ Cj~~-~s' ~/ <br />FIRST MIDDLE LAST / <br />Home Address z~l ~~ ~'V~ L k`~vJ~'~~ !"L. Ward: <br />f~ <br />Qualified Elector: : ~~~~ <br />This area to be completed by Clerk staff.) <br />Zip Code y~7t:'~ Home Phone ~/y ~ S/5~' C~~ 5"'7 Fax <br />E-Mail ~-~7t'-~-/'~1S T`~ ~'/~-~~.4,t~t Cel~/y .5 %~/- ~ ~,cu ~ Other <br />Employer -"- Occupation ~ % ~~~ <br />Work Address - <br />City ~ Zip Code .----- Work Phone <br />Soc. Sec. No.* ~'Driver's License Date of Birth ~,~~-~~~ <br />Years Lived/Worked in Santa Ana ~ Language(s) Spoken ~ K G ~~ 5 y~ <br />Organizations (Professional, Community, Service or other) <br />27~cazsf! /P, /U/tT~L L-c~/t,cl7o/ c3/=/ov .tit~/c ~uofrcz <br />Qualifications, Experience, Education ~-f~i- SuiCr,~'s,~. /f'/~'~N "ir ~`i+-v7%-lu~.c~„~;,~,r~L' ,:~1~~ ~uy~~„G, <br />r <br />Remarks (attach resume if available) ~ <br />C. ~-l-(/~~2 yr ~-G i~.f~l~~„z 1-fiov,`~'(.~v~` ~•r-'G~o~G~/•C~`o>LOU.~-~c~ <br />i~(K/>'TG%~C ' LLIG~~ l<U/~ G!~/ / /'F ~L % nL~/`f75 ~ ~ 17~y ~~"~ <br />9~. r <br />List Board(s) /Commission(s) ~) Select first choice: ~cT~I ~~r ~ G j~= Sa Cf ~~ ~cs ~i°lflrf / 5/ a~ <br />you would like to serve on:2) Select second choice: <br />3) Select third choice: <br />I am a registered voter in the City of Santa Ana. I have completed this application with the knowledge and <br />understanding that any or all items may be verified, and affirm I have received the Ethics Code, understand its <br />provisions, and pledge to conduct my duties consistent with the code if appointed to a City Board or Commission. <br />I consent to the release of information contained in this application to interested parties. I further understand that <br />the Santa Ana Police D~p~rtment conducts a routine background check on applicants nominated for appointment. <br />SIGNATURE ~ ~,~ (_-~t ~ DATE ~ ,j / <br />This field must be completed in order for the application to be processed. <br />This application will be retained on file in the Clerk of the Council Office for 2 years. <br />Please note that the Code of Ethics and Conduct Certification must be signed and received by the Clerk of the Council Office <br />prior to nomination to a commission/board. <br />D - 26