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Janice Ellis <br />From: support@civicplus.com <br />Sent: Tuesday, May 17, 2011 1:20 PM <br />To: Janice Ellis; Denene Taylor <br />Subject: Online Form Submittal: Appiication for Boards / Committee / Commission <br />If you are having problems viewing this HTML email, click to view a Text version. <br />Application for Boards / Committee / Commission <br />Firs# hlame* <br />Last 09101*000 ' <br />ArttlreW <br />47$ 3°Ist 1o <br />Cilr <br />Peft Stow `TX W 764, ' <br />()75462 <br />Tw1 <br />Telephtxte - <br />9037845= <br />(903)123-45$7" <br />Mra" ~ <br />Akport <br />~A~~ ~ ~~r►~~+r~ <br />w <br />Areas o# Inte~est <br />euftnvk SwWaMo <br />t } <br />PatWLaffw Cott* $Wd of, <br />H <br />l <br />h <br />Ccmtnlkwian <br />Civt~ ~ Cot ~ tn <br />ea <br />t <br />. ~ ~ ~ ~ ~ ~ ~o ~ <br />[)q EcD000110, D&VSk*1~t <br />Pq <br />Pubk Lbraty ~dvisorg+ ~ <br /> <br />~ ~ <br />Traffic Coma0sWon <br />Pq Hb4oft ~ r►0"0*` <br />t l <br />Zorin9 ~ ot A*wtrriant <br />. ` <br />[X] Housfw~ AWW* Board of <br />Gcmmlisslor~ <br />Please note.any spocial knowkdge, educatio►t, or <br />experience you have that is applicabb to the ftrnction <br />of the baard* commiWon, ar cAmmifte of iMerest <br />(attach addW,mai pages if necessary). If applicabte, <br />list dates of sorvice on any Ciiy baards, comrnissfons, <br />or committees. <br />Certificafion anci Auttta►ization <br />[ 1 Street Adviswy Bcyard <br />I acknowledge that 1 am aware and agree to the prohibEtitina of tte City of Parfs Cherter &,-4 the lams of 1he State of Texas regardrg <br />nepotism and conflicts of interest of appoi»tees ta Gity boarcls, coMmWsloM arid cortrrtttfees.1 also cerfify that i# appointei t wiR <br />attend at leas# 75 percerrt of a# regular meetings and shatt nak tave any delinquent ind ess #a the Gity during rrty term. F <br />understand tha# the number of positions on a given txrard, comnthsion, cu commfte is Iltiited and thati l may rticrt be appotted; <br />however, if Iarn not appairrted, Iagr+ee to be placed in a database for poesbW tuWm natitieattan of tcpics of InWast l certif'y that the <br />information given by me in this application is true and cornact aru# any tWw lni`twtaWn or mtsrepreserttation is suft[ent gmrnds for <br />disqualificativn. I authorize the GFty of Patis to verify atl infbrnabon provk#od irt this appkation. tn accordance v~th Seetion 552 of #he <br />Local Govemment Cade, i understarni tha# infoima#ion provided itt this appiica#ion may be avai#able to #he public upcn reiquest* <br />[X] Agree <br />* indicates required fields. <br />[ J oisagree <br />The following form was submitted via your website: Application for Boards / Committee / Commission <br />- - 204 <br />