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08/19/2009 04:54 90373::6154 1TTF.C_INSUR4NCE_HD Q PAGE 01 INTERNATIONAL FiRE &$Uii.AI1VG COmS REVIEW CIJMMITTEE APPLICATION The Paris City Council is seeking committed individuals who are dedicated to the well-being of the Paris community to serve on an ad hoc committee to review the Internationa! Building and Fire Codes and consider recommendations for adaption by the Councii. In additinn to thc general qualilications listed in the certiftcation belvw, other qualifcativns may 6e mandated by statute, City Charter, ordinance, vr resolution. P(ease complete the information rcquested below and return by Mvnday, AuguatA, 2009, to: City Cterk, 150 First Street SE/P.O. Box 9037, Paris, Texas, 75461. Lly Candidste Trtformation Namc:YLAi,s O fZ cJG-r'~ Address: q,-z Ce- L4 3 Work Ahon :C/*3~ S/g/ - 69.2 '7 Horne Phorte:~ 70-1~) 73 9$ 7 S-0 Fax: E-mail Address: lMRWD17-W /i-2Rt Q 9 j,4jw nleasc note any special knowledge, cducation, or experience you have that is applicabic to the function of the committee (attach additional pages if nececsary). Tf applicablc, list dates of service on any City boards, commissions, or cflmmittees. Personal Background Thc City Council is interestcd in appointing members with a general interest in the buitding 1nd fire cvdes but also reeognizes the need to have members with specialized knowledge. Please cheek the appropriate bax below and for "Other;" dexribc your occupation or ather appropriate background dcscriptivn. Atarm Contractor ❑ Commercial Building Cvntractor ❑ Downtawn Properly OwnEr Certification and Authorization 0 Kistoric District Property Owner "insurance Agent ❑ Other: 8y signing bclow, I acknowledge that 1 am awarc and agrcc to the prohibitions of the City of paris Charter and the laws of thc State of Texas regArding nepotism and conflicts of inierest of appointees to City boatds, commissipns, and committees. 1 also CCrtify thSt if app0imed i will attend at least 75 percent of alI rcgular mCCtingc and shall not have any delinquent indebtedness to the City during my tornt. I undCtstand chat the number of positions on this Committet Ate limittd and th8t I may ttOt be appointed; hawever, if i am not appointed, ( agree to be placcd in a datRbase for possiblt futnre notification of topics of interest. i eCrtify that the information given by me in 2hi3 appiication ic true and Correct and any fajsc inforntation or misrepreseatatioe is sufficient grounds for disquaf itiCation_ [ further affitm that ( have not prcdeterm{»ed a final oginion oa the adoptian of the lntCrnaNprtAl Building (:osfC ar tntCmationsl Fire Cqde and will approaCh committee delibcrations 8nd recommendations with an opon arid eonstructiv ind. I authorize the Cify of Paris to verifiy s(1 infoctttation provided in this appIieation. In accoMance wiih Section ,E~5Z e,LUCaI 4ovtrnment Code, 1 undertand tl,at information prov9ded in this application may be availabie to the pnblic ~o uest, i Signature of Candidate• Date: 5~// W C,t7 OFNfilq RE f,:: :i~ : 405 ~ Rcv;Aed 7/18f09 crry MMAGER . 2 5 6 PARIS. TEXAS