HomeMy WebLinkAboutAgenda Bill 4.A-Dooley 11/15/2010FLU City of Petaluma, California
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City Board, Commission and Committee Applic n h(�y['� �
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Instructions: Use this form to apply to serve on any of the City of Petaluma, Califo ° s g�"a 4
Commissions, or Committees. Please fill out the form completely. If a question does not a type or
write N/A in the space provided. When completed, please forward to the City Clerk's Of
Petaluma, I 1 English Street, Petaluma, CA 94952. All applications are reviewed by the City Coun
Name:
mavy'Doo 16/
Home Address, City, State and Zip Code:
320 IN0,1 n u+ 5�
Home Phone: (If appointed, do you want this
number to be available to the public ?)
❑ YES [9 NO
FAX:
Work Phone:
j O `l ) - 7 (R 5 - 15 22--*7.
E -Mail: (If appointed, do you want this address to
be available to the public ?) a YES ❑ NO
Are you a registered voter in Petaluma? I if so, for how long?
YES ® NO I �?, yn o Y1
Board(s), Commission(s), or Committee(s) of Interest *:
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*Note: To serve on the Senior Advisory Committee, you must be age 55 or above.
Have you attended a meeting of this
body?
❑ YES JON NO
Have you served on, interviewed; ordpplied
this body previously?
❑ YES 0 NO
DOOLEY, MARY
Present Employer:
Job Title:
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Previous Governmental Bodies /Elective Offices you have served, Position /Office Held and
Dates:
G--s to 1e1� o�- 5CA"Jn c'�jL.eti -tom �°� 1 ,eov-
Civic or Charitable Organization to which you have belonged, Position /Office Held, and
Dates:
`F?A - 4WM - A, Y s
What Special Interests /Skills /Talents would you bring to this Board, Commission, or Committee?
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College, Professional, Vocational Schools Attended (Major Subject, Dates, Degree /Date):
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Special Awards or Recognition Received:
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Please state reasons why you want to become a member of this. Board, Commission or
Committee, including what specific objectives you would be working toward as a member of
this advisory body:
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Is there any other information that you feel would be useful to'the City Council in reviewing
your application?
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O - I Y1 �, . ha,� done- sejv" n rgj P1C
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Are you associated with any Organization /Employment that might be deemed a conflict of
interest in performing your duties if appointed to this position?
El YES 9 NO
If yes, please state name of Organization /Employment:
City Policy directs all appointed, advisory body members not to vote on matters where there
exists a potential conflict of interest. Would you be willing to abstain from voting if such a
conflict arises?
YES ® NO
How did you hear about this opening?
'F�i-al wvta- 1 4 'rt5 (oun&j l <3 M7& T
Applicant's Signature
'Date
10/1- to
Revis�'d August 1 V,2008
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