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rint Form <br />CITY OF SANTA ANA <br />APPLICATION FOR SERVICE <br />r~" '' BOARDS 1 COMMISSIONS /COMMITTEES <br />f} <br />Name (Mr., Mrs., Ms.) Laurence ~) Flttterdale <br />FIRST MIDDLE (,,(AST - <br />a <br />Home Address 602 North Linwood Avenue Ward: ~' Cluaiiflted Elector: <br />fThfameaeo,beeam~etadb ClaksbllJ <br />Zip Code 92701 Home Phone (714) 543-7118 Fax <br />E-Mail larry@glendate.edu Cell (714) 317-1547 Other <br />Employer Glendale Community College Occupation computer science instructor <br />Work Address 1500 North Verdugo Road <br />City Glendale Zip Code 91208 Work Phone (8181240-1000 <br />Soc. Sec. No.* 545-fi0~673 Driver's License No. H0404676 Date of Birth dune 12, 1942 <br />Years Lived/4Vorked in Santa Ana 60 Language(s) Spoken English <br />Organizations (Professional, Community, Servics or other) <br />Qual'Ifications, Experience, Education <br />Remarks (attach resume if available) <br />List Board(s) /Commission(s) 1) Select first choke; Historic Resources Commission _ <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 <br />PoliceppDepartment <br />conducts a routine background check on applicants nominated for appointment. <br />SIGNATURE ~A..uw~r_.i/ '~~t:ii DATE SI-ir`c+~rnan )G1 ~ !? Jt7 <br />Z7-'zr-- <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 tltatthe Code of Ethics and Conduct Certification must ba signed and received by the Clerk of the Councl Office <br />prior to nomination to a commissionlboard, <br />D - 27