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P a g e 1 CCLK—B&C Rev. 03/12 APPLICATION FOR APPOINTMENT TO BOARDS AND COMMISSIONS PERSONAL INFORMATION: Mr. Ms. Name(First/Last): Date: Home Address: City: Zip: Mailing Address: City: Zip: Daytime Phone: Alternate Phone: Email Address: The City of Anaheim uses email as the preferred method of Communication. Is this acceptable to you? Yes No If you have checked “No”, please indicate your preferred method of contact: Mail: Phone: GENERAL INFORMATION: Are you a Resident of the City of Anaheim? Yes No Are you eligible to vote? Yes No Have you previously served on a City Board or Commission? Yes No If Yes, which one(s) and dates: Are you a paid employee of the City of Anaheim? Yes No If Yes, give position and work location: The Park and Recreation Commission has one seat with a minimum age requirement. If applying to this Commission, please answer the following: Are you age 60 years or over? Yes No Budget, Investment & Technology Housing & Community Dev. Comm.*/** Public Utilities Board*/** Community Center Authority* Library Board Sister City Commission Community Services Board Parks & Recreation Commission Cultural & Heritage Commission Planning Commission*/** A separate application should be submitted for each Board/ Commission you are interested in serving on. For Office Use Only: ---PAGE BREAK--- P a g e 2 CCLK—B&C Rev. 03/12 CITY OF ANAHEIM APPLICATION FOR APPOINTMENT TO BOARDS AND COMMISSIONS EDUCATIONAL BACKGROUND: PROFESSIONAL EXPERIENCE: WHAT ARE YOUR OR EXPERIENCE TO THE BOARD OR COMMISSION DESIRED? : ---PAGE BREAK--- P a g e 3 CCLK—B&C Rev. 03/12 CITY OF ANAHEIM APPLICATION FOR APPOINTMENT TO BOARDS AND COMMISSIONS REASONS YOU ARE INTERESTED IN SERVING ON THIS BOARD OR COMMISSION? I declare, under penalty of disqualification and termination, that all statements in this application are true and correct to the best of my knowledge. I further declare that if I am appointed, I will serve fairly, impartially, and to the best of my ability. I further acknowledge that information contained in this application is a public record and may be subject to public inspection pursuant to the California Public Records Act (CA Gov. Code §6250 et seq.). I read and understand the above statement. Executed on: Signature Date Return to: Office of the City Clerk City of Anaheim 200 S. Anaheim Blvd., Ste. 217 Anaheim, CA 92805 Office Hours: Monday — Friday 8am‐5pm. Telephone: (714) 765‐5166 SIGN ---PAGE BREAK--- P a g e 4 CCLK—B&C Rev. 03/12 CITY OF ANAHEIM APPLICATION FOR APPOINTMENT TO BOARDS AND COMMISSIONS SUPPLEMENTAL INFORMATION: ---PAGE BREAK--- P a g e 5 CCLK—B&C Rev. 03/12 CITY OF ANAHEIM APPLICATION FOR APPOINTMENT TO BOARDS AND COMMISSIONS The City of Anaheim has a number of boards and commission on which citizens serve and make recommendations to the City Council in an advisory capacity. In most cases, you must be a resident and a qualified elector to serve. Terms range from three to four years (July 1 – June 30) and appointees may serve up to two consecutive terms. Applications are accepted throughout the year by the Office of the City Clerk. Applications are reviewed by the City Council at least four to six weeks prior to a term’s expiration date and as unscheduled vacancies occur during the year. Applications are maintained on file for two years from the date of the application and may be updated at any time by resubmitting a new application to the Office of the City Clerk. *Certain Board/Commission appointees are subject to filing annual Statements of Economic Interests pursuant to provisions of the California Political Reform Act of 1974. If appointed, you may be required to fill out a disclosure statement that identifies certain financial interest(s) beginning with immediate twelve months period prior to appointment and every calendar year thereafter during the tenure of your service. **Certain Board/Commission appointees are subject to participate in State‐mandated ethics training (AB1234) within the first year of appointment, and biennially thereafter during the tenure of your service.