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Print Form <br />CITY OF SANTA ANA <br />APPLICATION FOR SERVICE 26 <br />BOARDS /COMMISSIONS /COMMITTEES DI d E <br />Name01 <br />r ,Mrs., Ms.) <br />FIRST MIDDLE LAST <br />le— v t'�It7 <br />Home Address Ward: Qualified Elector.,. 5-- <br />- (chis area to ho comp leted'byVerksfafl } <br />Zip Code F27p Home Rhone , Fax <br />EMI � , .:_........�.........�. � � Cell <br />Work Address <br />C ity <br />MA <br />Zip Cade 4 <br />J P17P 0q Work PhoneAW172- <br />Soc, Sec. No river's License Date of Birth <br />Years Lived/Worked In Sante Arta Language(s) Spoken <br />Organizations (Professional, Community, ServicD or othe <br />a <br />Qualifications, Experience, Education A''1 <br />Remarks (attach resume if available) <br />Dist Board(s)1 Commissions)) Select first choice: <br />you would like to serve on: 2) Select second choice; <br />3) Select third chok*: <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 />consent to the release of information contained in this application to interested parties. I further understand that <br />the Santa Ana Police Department condueturine background check on applicants nominated for appointment. <br />SIGNATURE n _ �-� GATE g - <br />. This field must be completed in order for the application to be processed. <br />This application will be retained on file In the Cleric of the Council Office for 2 years. <br />Please dote 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 commissioWboard. <br />C-25 <br />