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HomeMy WebLinkAboutStaff Report 4.B Appointments Part 08 Senior 06/20/2011SENIOR ADVISORY COMMITTEE FIVE VACANCIES FOR TWO -YEAR TERMS EXPIRING .JUNE 30 2015 124 Hillery, Judith Senior Advisory Committee gay �e►z�a� hf ®ria _ City Board, and Commi#fee 'APP lic: tin q Instructions: Use this form to apply to serve on any of the City of Petaluma, Californ ards, Commissions, or Committees. Please fill out the form completely. If a question does not apply, write N/A in the space provided. When completed, please forward to the City Clerk's Office Ci Petaluma, 11 English Street, Petaluma; CA 94952. All applications are reviewed by the City Council. Name y ] Judith Vivas Hillery Home Address, Crty,.M* and,,Zip Petaluma, CA 94954. Home,Phone (If_appointed do you wont fhrs ci number to`be avrlable' to the.'publrc?) a W6rk,Phone 5 ❑r 19 YES, - - E Mail (If appointed d 66 want th►s address to FAX: P ® ES ❑ lab ?) Y c NO . be agar lei to theE publr , , k Are °,you a voter in;,Petaluma�` If so,!for how long? .u( z is , nit 1 - ' ;p <.. , �� W iR` h- :5- � Y ,• .. , .. ❑✓ YES ❑ NO 34 years Board(sj, ,Commission(s) or,CommitFee(s) of Interest": Senior Advisory Committee *Note: To serve on the Senior Advisory Committee, you must be age 55 or above. Have you attended a neeting�of this= .. Hove youtseryed on`mterviewedr or applied for b0 � y ��/ , this�body previously` ° / , o '., �., rc�.dw ❑ YES ❑ NO .., .• ...... ❑ 'YES ' ❑ .. PIO Hillery, Judith Senior Advisory Committee gay : IPresent$Employer Retired g l , Job Tithe ° 4 Previous Governmentdl Bodies /Elective` Offices you hove +served,Position %Office Held and �. } °�ti de V�.i a,'Id AAA 4ir da 74q ya i 1Palf 14 �.d4 �? 1=3 ��a °r h ` ai° "A IAaf ""llwjSe9T "� f .ti. Civic or y Charrtal le Organization to aihich you have. belonged "position %Office_ Held; =cnd; Dates , . .:: ! • E � �° y ,- 5 � _ - �1 A. L Served on the original PEP "Board' 1977 and served thru 2001 dt Special Interests %Skills%Talents would you bring #o this Board `Commission, or committee ?_. �Uh = Retired R.N. Career included: Army Nurse Director'of,Nursing at Beverly Manor Convalescent Facility Supervisor Medical Review, Aetna Medicare claims Medical Review, 'G,E. Long' Terris Care Claims' Page 2 of 4 13-0 4- qi. 6 - bill dr,`SUbjd'etVDdt6i; e/ i) h: Profession' I V q on 6 Ddle R. N.- Methodist Hospital School of Nursing 1961 b Recognition , eieWe e. 'd" Aw a r ds . or ecogn pi ease, Wod state -- riE4iio6swlI �,&j wd to 6ecomea ;'me"'m'b6'r' this " o'6r'd,I` on or j"Itted, including Vbtild'W� dogjoi4ar as . a meri . mbot of '- .,Cbni iliolg whciitiili cli4c objec ev, this p"i&V bb, Time ' to get involved again and hopefully help inter-connect sen 16r programs to benefit more individuals. - ...... ... . I I . t , t - Is`there any other inform you feel would be useful to t C ouncil wreviewing, PP'llddflon?'- YO Page 3 of 4 131 Revised August 12, 2008 Page 4 of 4 l 3�- Are you c ssociated with any Organization/Ernploymer�# thctfmight be deemed c Iconflhp jof interest iri'performmgiyour duties a�ppointedjto #his position ?4 ❑ YES ❑✓ NO H of If yes, please state name "Organiiation %Employment''' : ity'policy directs all appointed, odvisory body members,not`to vote on matters where there . exis conflict of interest Would ou,be wrllin to abstain�from vofi ng if such ,o u y g i } ao�tential I< Cor�i i r . ;. � ❑✓ YES ❑ NO a d •: �' ,��' - T F;�; ,� � �;v � ' ° � hid: F ,t;, _ -.- Hove did you hear about this opening - Info sent to me in the mail I �Apphcant's %" Date r Signature / I 06/04/2011 .R N W i Jones, William Senior Advisory Committee 33 a C'a ®f'hetalzuaa,. ®nta4 n . $CitytiBoard, Commission and Cornrnittee Application Instructions: Use this form to apply to serve on any of the City of Petaluma, California's Boards, Commissions, or Committees. Please fill out the form completely. If a question does not apply, type or write N/A in the space provided. When completed, please forward to the City Clerk's Office City of Petaluma, I I English Street, Petaluma, .CA 94952. All applications are reviewed by the City Council. If `you have questions about this form, please call the Ci Clerk's Office at 707.778.4360 or e -mail us at cif clerk @ci. etaluma.ca.us. -Name ti o MAY 2011 �LL A- /11 � V � CITY CLERK t ., M 11�P i o:" k tiD MA Home`Atltlress, City, Std'te Zip C de v rr„ . A e'll - T C 7 L aAl A— G14 547,9_5 2 HomePhone (If appomteddo you wantthis� " °, �' numfje� to be , e tVi , e public? Wo :0k. Phon Q e X t � YES ❑ NO K _.. a.a ., >....,.. 5.0 ,�.rs.' g a..3 J ".'54�' EMail�( If ,you�yanttiis�address to FAX ' `AYES r : r� r dm ,:.. X xu; beq�%ailab'Ietotlie'public2J , N y ^y , �{d r�ra.;. z f N *M'a✓ k� Awly�ou�a ,I Fasn V how alu ma = �r+a.. - registered vo t,� �� �: Mv, *S° iY k t b o long �� If so,�fr G x v - t Y w r. =, 'Y0.Y .:..: ,wv ,.... .'�: k ., a' i 55 v5 " A. � DY ES ❑ NO Board;( s); �Cornmission( s9 );"or �� �� �������� � � ,,� � , S4A, A-D V /S©lzy CoMM/ TTEE *Note: To serve on the: Senior Advisory Committee, you must be age 55 or.above. AdA , a...' '�',.�,<F..c...i. �= .; thi� °` re�e.,* .` su,, ..v..m�..."��F-��-.�i ~ 1..;�,a Haveyou meetr youservedon mterviewed,orappliedfor',:, W. t attendeda G ii�ave ys ATY`'�Bt�S� $*$'�0 body, Y jC bod reviousl YAP Y ,�" �r� athis h� AYES ❑ N O DYES ❑ NO N W i Jones, William Senior Advisory Committee 33 Present Employer" v Job Title = }P [ ?- /✓� I O Z_zM / Q- f'revio'us�Gouernmental, Bodies /Elective�'OfficesY ou Position /Office Held�and ` Oat .5 :1D / 121 /Z/81v /1il F�/Z A A-Iid'Ly- T =CivicorChantableOrganization towhich you have belonged, Position /Office Held, and 7 D - 5 25V 7 AJ4-77 ,0 A-' A-L— j��� IM A-11 ON tFle- P��I � � /Sc�CIEF r4 T 91 &: s :` ^a .ter 4'.`�..kY £�:,�"::'" .. . se _ 1Nhat Specia Skills %Talentswouid��you,,bnng Board, Commission, ; or Comm kp MW ,.� �a . R OOM 'n 'ie�F 1V,157-,e--7 AC-5 -tom -5:5 OP 6� :Z-.e- ! KT c aM Page 2 of 4 /L;l 7 .. College, Professional, Vocational Schools Attended (M at or,Subtect;'Dates; Degree /Date) .ai. tin A45 19 /9 93, R OA S ecial =Awards.;or Recognitio p n Receryed a'J t ��y Please state'reasons why you,wantpto� become a member of this:Board „Commission or Committe6, — A µ 6 whdf!iP�ec objectives you woulc p.working3dwaidias a member of ' s�"adviso bod_ } �,1.* U� •+,g, '. tlx y. r4 >s �•.. tr+w w.u, ° .&� ".�3R. a ,TA A,14 g; M & 1�i[r&sS /=o jz �r of 7 ,. ,..ro —, fi r_.. •r +dYlf.. M e. �.. ci �. i.• .,. ` hM Is ;there�any other you feelywould be, useful to theCityCounl in;re�iewing a.r� �'� A'E 7 �dj • " { hr ° ra } tiAd t.` your application U r s. M r* x! n s 4 t 4 r gat Page 3 of 4 ��S Revised May 9, 2011 Page 2 4 of 4 �2b Are you assocatetl wr#h�anyQOrganization /Employment *that,might be.:deemed q'conflict of . �: Vi ll e l l I m� erformin ourdutiesif a ointed Ffo thisMposition� P Y PP » 9 1 , ❑ E YES NO n s If yes; pleases 'stateknarne�°of�Organization %Employment $ directs City policy appointed, advisory bod,.`y rnembers.anot fo rote qn matters wherethere a , exists a potentialxconflictof interesf3Wou1d youjbe .willingatoaabstain�froni�oting if; =such a <conflict,arises? R° B ' YES ❑ NO k 2 How did you hearf v , < x ,,,ai .cr ST,�L J� TZ �l,d -FT ��Ti4- LCl/La 42- `NIUIZ /UT� / TTe Yr Yp $ In f ' U �n X tiA;c 9 3'" .`4✓+" Applicnt «s Signature { Y'�' A ! Date a, ri� Rr`. t m 1 t"" 7tI74r "; v X�ai` 3' Revised May 9, 2011 Page 2 4 of 4 �2b 51222 2 k ¢ Y .I I °.. n �j/ II Q ,/� 1 /� II� /� "! L 1 y �> fi AD J► �] iI R r Y �,'' .r r � x ��: �' a � ®� rt- �i �B�Bd�99 L46 �Y.i 84 tl d':b�� � [� 1 i oard; CommissionGarid Commett" �►° lica_ts :A Instructions: Use orm to a to serve on any of the City of Petalu Ca i o o r Commissions, or Co a fill out the form completely. If a question of apply or write N/A in the space ed. When completed, please forward to the City y of Wuncil. Petaluma, I I English Street, Petaluma, CA 94952. All applications are reviewed by the F Home Address, City, State and�Zip Code: 3._ _. _.. ti aHome Phone (If appointe' d do you want th s V�ork � ;number to,be ava►labletg the ubhc a�g ` ��Phone . ',, ;.� � a ❑ d0 .�: = - _ _ - }YES .:: _. " tl ` j - = � r E AAail (If apporrited do you an this address to - be availobleyto$theWpubbc ®, YES'..,® NO Are . � o are Ister ed voter m Petaluma Y, � If so,for how`long? F . ,I z - YES . NO rv 6oard(s), Commission(s), or, Committees) of Interest:_ *Note: To serve on the Senior Advisory Committee, you must be age 55 or above. ,: ESQ. ,�.,� r,F :. -,.:.. Haveyyou attended a meeting of this ' - Have you�served onkrnteniewed, or dpphed for =body _ thin body previousiyn ?' w `71 YES ® NO YES ® NO -pre, Martini, Bonnie Senior Advisory Committee !37 X O � � U� U rc, A- ff" y,6ti., Positi6�Z6ificejHdId and ivpl ices. pp - 'Ddtds! 01 1" t Sel r 71 5 a / ��`r _e� nHeld iz io d' 6ild i9n i ­to O.Aojopg "Pb''it' H av 4 E� ,CITOOI a 4 i, i —N J Q/ I / S j r iv V'k 7/, lo j 7_6 l y Wh N 'th* LBddrd icit-SO66 al killi/,, .,�,60 �bnng,, _or- Committee?' lye C. WO; WO h Ai Page 2 of 4 G9 LCollege'�Professional, Vocational'Sc_ hools Attended (Major Subji6et Dates Degree/Date) z qg '_b V.h "' ��Y IW t *'� ddF N. .ha�� �; ` hi , +' � N i�• ,p µ' �� n �'� ^ ` - - ''y�7 a j,° yd, + : � 4 i � F�_,. . -, t �'. r � ?Ar v -- „u m -' .: Special Awardstor ,IRecognrtion Recerved:,n -_ y �i� �a� _—� r� c �r � ii :. Piease state reasons why you;wanf;to become`>a member of this Board;, Commission or Committee, including what Speck_ obtectrves you would a orkrn as wg fo a_member of Y h r —' aPiis ddviiory body w _ I. iY.'•�.� at _ E. , / ZOO� � _ :Is t e�eanyfiother�nfo "rmat�on;that you feel wouldFbe�usefuLto the;Crty,Counci �n reviewiing .� .4 S c- Page 3 of 4 135 Revised August 12, 2008 Page 4 of 4 ra- YES-0 NO x, m ta" t If yes "please s tate .Erriploy 4��, . 771�� T t ud "th' di PP idt�;'tb- ere,, ere- Cit Y - ok 8` 6 d h pppmp4p-, ylspry�.,b y merrlDersi a rc Ahktf p !U h exists a willing s uch a T. ,,c s?' '1 4 1 4 El YES NO id" -- ni ? 4H ow ou ear.QD Uft ign urei! L Revised August 12, 2008 Page 4 of 4 ra-