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w <br />Name (Mr., Mrs., Ms.) <br />CITY OF SANTA ANA <br />APPLICATION FOR SERVICE <br />BOARDS / COMMISSIONS / COMMITTEES <br />Laurence <br />FIRST <br />Home Address 802 North Linwood Avenue <br />Zip Code 92709 Home Phone (714) 543-7118 <br />MIDDLE <br />Print Fonn <br />�J <br />j 2-H tterdale <br />C LAOS T <br />Qualliflod Ellectar.3( fit <br />N to be ecru 0o fed by Cl** Luff.) <br />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 818 240-1000 <br />Soc. Sec. No.* Driver's License No, Daae of Birth <br />Years Lived/Worked in Santa Ana 8Q Language(s) Spoken English <br />Organizations (Professional, Community, Service or other) <br />Qualifications, Experience, Education <br />Remarks (attach resume if available) <br />List Board(s) / Commission(s) 1) <br />you would like to serve on: 2) <br />3) <br />Select first choice; Historic Resources Commission <br />Select second choice: <br />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 Department conducts a routine background check on applicants nominated for appointment. <br />SIGNATURE r _ DATE �, jG� a 2 ld <br />' This field must be completed in order for the application to be processed. <br />This application will be retained on Me 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 />