Laserfiche WebLink
Name (Mr., Mrs.k Ms ) <br />CITY OF SANTA ANA <br />APPLICATION FOR SERVICeoll W11 28 Pik 2= 34 <br />BOARDS / COMMISSIONS / COMMITTEES <br />Jikzee�-R-i/�+- <br />FIRST <br />MIDDLE <br />CIT; ��ta <br />CU[ <i C <br />C�2�s� <br />LAST <br />Home Address r�1 a� Uva �`h`��'p� Y'L V6 <br />Zip Code V-1-704 Home Phone '71Y-015- 03sr'7 Fax <br />Print Form <br />E -Mail nc tf J215 T`i e_/?D •e.o,Y Cell LtD7 Other <br />Employer <br />Work Address <br />Occupation 7-14&.p <br />City Zip Code -- Work Phone <br />Soc. Sec. No.* Driver's License No Date of Birt <br />Years Lived/Worked in Santa Ana Language(s) SpokenN <br />80&P j,) cb //Lfe-rorz,j S/+G F" ct.tii Dig?�o.✓� <br />Organizations (Professional, Community, Service or other) <br />�ni-2?��� iP, N/-rT�[.. f-r�R��yo✓ d!'�� �/KI� lvvfrQ <br />Qualifications, Experience, Education 1f-11- <br />t� - ��bC� 6 Ctx1.�1G/ ZvDHItK - / <br />��% �� l� / ��'7. 11F-1 ��� S / r ,. �a G✓II'.)d l�Hi�g..a! � <br />C p - CNlj-/ rL D r 6/ 6N,3oi2 <br />Remarks (attach resume if available) 4. Y <br />List Board(s) / Commission(s) <br />you would like to serve on: <br />1) Select first choice: <br />2) Select second choice: <br />3) Select third choice: <br />C <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 [?Xp�rtment conducts a routine background check on applicants nominated for appointment. <br />SIGNATURE (LQ.[__aL __DATE 2j 1 <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 />C-32 <br />