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Janice Eliis <br />From: support@civicplus.com <br />Sent: Monday, May 16, 2011 12:18 PM <br />To: Janice Ellis; Denene Taylor <br />Subject: Online Form Submittal: Application 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 />Fimt Name*~ <br />~ag <br />~ <br />AddreW <br />P <br />Ctty" <br />Tetephcane <br />(9W)123-40W ' <br />Akpo <br />Areas of In ' <br />Pq; Et" <br />conx <br />'mobw <br />HOW <br />Cat'E" <br />[J ~ <br />Please note any spwW knenn*d9e, educatian, or <br />luay 12th 4 <br />8Xp8fi@FiCB ~ hwo ~ is aW116011510 tfl ft <br />fUfldfNt of the , comm"fN'f, or CiiF#N~'1 of <br />Iflt81e5t (attach ~ If k1 ty}. {f` <br />applicahte, No# dates of wyles on any C#ly baards, <br />COt'I1t11fSS10fa, Or"+ComCtt <br />Certiflcation amd Authotftstfvn <br />I ackno+vle ttrat !€m swam ' and Vre8 t4 the prohbftm of tlhe <br />nepatism ariO t;cxni'llicts of hAerest of PPokt tD Gity kotrft, Ow <br />attend at teag 75 ' of aa# regular rneetings and sW ntA hom pemwd understand tha# ft rtwnber of pasttkOns at a given koard,'samrrus <br />however, ifi !arc ttiot appak#jxf. l agm to be pleoW it► a taU► <br />disqualfficaftn. t atWtot'ize the City+ of Paft <br />Local Gaveaoment Ccde, i understand that <br />[XI a9ree <br />' indicates required fields. <br />[ l Disa9+roe <br />t <br />vAttt S,609,00 W Of te <br />ft upon tequest.` <br />The following form was submitted via your website: Application for Boards / Committee / Commission <br />- - 218 <br />