HomeMy WebLinkAboutS05-Mayor's Office
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o CITY OF SAN ~ARDINO
Application for Consideration for Appointment
to citizen Commission or Committee
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Personal Data ._j
Name: '/<. ~)..i t7 L-.- is ;4 R: <;
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Home Address: ~7-09 d-c, K' '" I
Date of Birth: ///1 j/r Telephone:I1I'/) Sij"'-j'r'lf
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Have resided in the City of San Bernardino since / '1 dt,
Marital Status: ,}l'/KYI? r/community Affiliations:
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Education j"
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Past: Em'Dlovmant:
3/ J C.;p5.
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Current Em~lovment
Firm Name:
-Tt~.2--
Phone:
Address:
Please Indicate What committees/Commissions You Are Seeking Consider-
. ation For: S c:,.' Ie rc ..} .,: r- d ,,,..z.
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Have you ever been convicted of a felony? Yes___ No~
knowledge. I under-
Economic Interests"
the codes and ordi-
California,
The information provided is factual to the best of my
stand that I will be required to sign a "Statement of
form as required by law, and that I will abide by all
f the City of San Bernardino and the State of
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Signa
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Date
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