HomeMy WebLinkAboutAgenda Bill 5A-PublicArt 08/03/2009 ~2,~2~2425Z6~~~~~
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- City!,Board Commission arid_ ,CommitFee Appl " 'on
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Instructions: Use this form to apply to-serve on any of the City of Petaluma, California's d ~ ,
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, 11 English Street, Petaluma, CA 94952. All applications are reviewed by the City Council.
'Name-. ~ ~ -
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Home Address, City, State and Zip,'Code;,
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Home Phone:.(If appointed, d_oFyou want#ijis __
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n'urriber to be avdilable to. the public?J; °Work'Phone::
YES 'WO" ~• ~. _
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l ~ E Wail:. ~If appomted do :you want this address to
J~" be avdilable~=to .the~publie~J -~ YES ~- ^ ~fVO '
;'Are you a registered voter°~nPetalumd? '1f so„for how"long?
YES ^ NO I i ULI~ i /1 -IWI,uM~k
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~ui3ocrd(s),'Commission(s), o~ Committee(s), of interest'~~ . -
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*idote: To serve on the Senior Advisory Committee, you must be age 55 or above.
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Have;.yo,"u~aftended a ;meeting of tFiis _ ., ,
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Have you, served on, :nterviewred 'or applied for
body? ~ ~~ ~ this''body previously? -
YES ^ iV0 ^ YES NO
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Hallock, Eileen
Public Art Committee
Present Employer:- ~ - -
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Previous Governmental`Bodies/Elective`Offices°-you have=servetl Position/Office Held-cnd
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Civic:;or Chartable Organizcton to_arhich you~have belonged, Position/Office lteld, and
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°-NUhgt~Special Interests/Sk~lls/'falents;would you,brmg to.this.Board, Commission, or Committee?
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Special Awards o~~ Recognition Receive"d
Piease}state reasons why you want to become a-member of tl'us~Board; Comm~ssoon`or
Commrttee~ including what specific~objectives you would„be worlcin`g-toward-cs a "member of
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this advisory body ~ _ _ .- _
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~Is~the~e~any_other~~~infor''riation~thatyou~feei would be`useful to the~Crty Council:'in reviewing
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your':application? :. _
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Are,.you asociafed with any:=Organization/Employment that might be ,deemed a coriflict~of `~
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p _ 'dunes if°a ofnted to°this posrt~on~ _ ;.: ~ -
interest in" _ erformmg~y"",our pp
^ YES NO
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If+yes, please state name of Organization/Employment _"
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City policy directs all-dppo~nfed, advisory„body.members not to vote:,on masters where there f-
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exists a~potent~al;conflct of interest: Mlould you be willing to•abstain from voting if=such a . _ '
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°conflict arises? . ° ' " _ ~ '
YES ^ NO
Revised August 12, 2008
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a ^ ~ ~'~ ®Peta~u~ac~9~'~'adi ®~nn~c~~ : ~~ ~~
.City Board; Commission and Committee Application's ; . ~~ ~~
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Instructions: Use this form to apply to serve on any of the City of Petaluma, Cara ~nia's Boards,~'~
Commissions, or Committees. Please fill out the fiorm com letel : If a uestion does no~``y" I , t e `or ~..
P Y Q QPP~ ~~Y,p~~
write N/A in the space provided, When completed, please fbrward to the City Clerk's Offrc~~Ci' of.
;Petaluma, 11 English Street, Petaluma; CA 94952. All applications are reviewed by the City Council.
Name....
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HomeAddress, City, State and Zip Code:. - -
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H"ome:.Phone`..-(If.,appointed do•~you.wanfthis,
number;to'be available;to the public?j ;'Work Phone'
-YES . ^ NO _
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~~ ~E-Mdil :(If appointed do you wanf this address to,
FAX °.. ~ _ ~^ YES D 4 N0 ,
be available to the public) .
Are you a registered voter in;;Petaluma~ ~~ •`If°so„ for how long?
C~' YES ^ NO
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Board(s), Commission(s), or Committee(s) of Interest*
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,~Note::To serve on~the,,Senior~Advsory,.Committee, you must be age 55 or above.;..
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Have you attended~a me"eting.of4this °, Have yo.u serued on, interviewed, of applied for
body? ~ • --,- this~body previously? "' ` `~
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~,YYES `^ `1V;0 ~ - ~ ~,~ YES ^ ~.1V0 `' ' ~N
~''~ '' • ~' ~'~~~ ~ ~ Jonas, Larry
Public Art Committee
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Present=Ernployer: ; . :~r ..:
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..Job Titfe:
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Previous Governmerital:Bodies%Elective Offices you: have served, Position/Office Held and` _
Dates: ~ _
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Civic or Charitable Organization to which°you have~belonged, Positior/Office.-Held, dnd
Dates: -
What Special Interests/Skills/Talents would you'bring;to this Board,. Commission, or Committee?
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College, .Professional, Vocational Schools Attended (IVlajor Subject, ~Dates,`Degree/Dafe) ..i
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Special Awards,or Recognition Received: ~ -
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<Please state reasons why you want',to become: a member of th~s~Board, Commission or
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,Committee;` including what specrf~c objectives`you would; be working ,towcird~ as a~~mernber,;of
his aduisory:body ~- .
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,Is there any~~other'information,thatyou;feel wbutd=be useful=to fhe City'Council in reviewing ,
your dpplication~ ..'~
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'Are yo.u associated with'any Organization/Employment that might be;deemed a conflict of
:irterest,in performing~your duties if appointed~to this positions
,.
^ YES `~ NO
If yes, please state name of Organization"/Employment:
~• ..
City policy directs all appointed, ad~isory;body~members not tovote on matterswhere~there
;exists°a:potential~conflict of int'erest~'Would yoube w~illmg`fo absfain from vofing if such a `
conflict arises?
-YES ^ NO
How did you hear about this openings .,
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:Applicant's Signafure ~ `Date
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~Revis A st 12, 2008
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