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Home My WebLink About2007-04-16 Appointment Submitted via e-mail to Stephen Long, HCDC staff April 11, 2007 Members of the Iowa City City Council: I regret to inform you that I must resign my appointment to the Iowa City Housing and Community Development Commission because I am relocating out of the Iowa City area. I am leaving Iowa City to pursue a master's degree in public policy and international relations at the Woodrow Wilson School of Public and International Affairs at Princeton University in Princeton, New Jersey. My final meeting as a commission member will be the April 19th, 2007, meeting. Thank you for appointing me to the commission in July 2005. It has been a rewarding and enriching experience to serve as a commission member, and I believe that the future holds great promise for the people of Iowa City. I hope that future undergraduates at The University of Iowa will become involved with the entire Iowa City community and continue our work toward a more positive relationship between the city and the student body. Sincerely, Tom Niblock ~ '1 r\,) :;,:,," -.. I',) I'.> c:::J NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: HUMAN RIGHTS COMMISSION One Vacancy - Three-Year Term Ending January 1, 2009 The duties of the members of the Human Rights Commission are to receive and to determine the merits of human rights complaints alleging unfair or discriminatory practices in the area of employment, credit, public accommodation, education, and housing. The Commission shall provide conciliation and the enforcement necessary to further the anti-discriminatory goals of the Human Rights Ordinance and to protect citizens from unfounded charges of discriminatory practices. The Iowa City Human Rights Commission has an obligation to investigate and study the existence, character, cause, and extent of discrimination in Iowa City in order to eiiminate discrimination by education, conciliation, and/or enforcement. It is also the duty of the Human Rights Commission to draft revisions to the Human Rights Ordinance if necessary to eliminate prejudice, intolerance, bigotry, and discrimination. Iowa City-appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Human Rights Commission meets once a month at 7:00 p.m. Applications must be received by 5:00 p.m., Wednesday, April 11, 2007. The City of Iowa City encourages diversity in the appointment of citizens to boards and commissions. Persons interested in being considered should contact the City Clerk at City Hall, 410 E. Washington Street. Application forms are available from the Clerk's office upon request or on the City website at www.icgov.org. Questions about the Iowa City Human Rights Commission should be directed to Stefanie Bowers, Human Rights Coordinator at 356-5022. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step-father, step- mother, step-child, aunt, or uncle. (Resolution 85-354) Males: 2 Females: 6 Council Announcement Date: March 5, 2007 Application Deadline: Wednesday, 5:00 p.m., April 11 , 2007 Council Appointment Date: April 16, 2007 HUMAN RIGHTS COMMISSION One Vacancy - Unexpired Term Ending January 1, 2009 Sehee Foss resigned No applications received as of Wednesday, 5:00 p.m., April 11 ,2007 [&l Denotes applicant completed the Confidential page of the application. 04-16-07 22b , I NOTICE THE CITY COUNCil OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOllOWING COMMITTEE: PUBLIC ART ADVISORY COMMITTEE One Vacancy - Three-Year Term Ending January 1, 2009 Duties of the Public Art Advisory Committee include developing by-laws and procedures for the Iowa City Public Art Program; administering the Public Art Program by determining the placement of public art, the type of art to be used in a specific project, and the artist to be engaged; overseeing the acceptance of gifts of art; overseeing the maintenance and disposition of public art; and overseeing expenditures of the Public Art Program budget. Iowa City appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Public Art Advisory Committee meets the first Thursday of each month at 3:30 p.m. Applications must be received by 5:00 p.m., Wednesday, April 11, 2007. The City of Iowa City encourages diversity in the appointment of citizens to boards and commissions. Persons interested in being considered should contact the City Clerk at City Hall, 410 E. Washington Street. Application forms are available from the Clerk's office upon request or on the City website at www.icgov.org. Questions about the Iowa City Public Art Advisory Committee should be directed to Karin Franklin, Planning & Community Development Director at 356-5232. Piiblii! Aiit Advisory Committee Attendance Record 2007 Term Name Expires 2/1 Emily Carter Walsh 01/01108 X Charles Fellin.. 01/01/09 X DaLayne Williamson 01/01109 X Emilv Martin 01/01/08 DIE Mark Seabold 01101110 X Rick Fosse DIE Terrv Trueblood X Key: X Present o Absent DIE AbsentlExcused Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in-law, brother, sister, brother- in- law, sister- in- law, step.father, step- mother, step-child, aunt, or uncle. (Resolution 85-354) Males: 1 Females: 3 Council Announcement Date: March 5, 2007 Application Deadline: Wednesday, 5:00 p.m., April 11 , 2007 Council Appointment Date: April 16, 2007 PUBLIC ART ADVISORY COMMITTEE One Vacancy - Unexpired Term Ending January 1, 2009 Charles Felling resigned Annadora Khan [8J 923 Dearborn 5t Patrick Carney [8J 514 Oakland Ave Margaret Furlong [8J 326 Hutchinson Ave [8J Denotes applicant completed the Confidential page of the application. \..>ILY VI IVWCl \.IllY Advisory Board/Commission/Committee Application Form I: I -...= -~... ~~~:!:~ ~... """'~ ...,... CITY OF IOWA CITY Individuals serving on Boards/Commissions/Committees play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. This form may be filled out manually (please use a black ink pen), typewritten, or electronically (PDF). Return the application to City Clerk, 410 E. Washington St., Iowa City, Iowa. THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name tfJ~ Wr;r-It~ Youth Advisory Commission, Age on the date offiling:D Age 15 to 17 (or) Term -~- "'c' ~.- .;;:'J D ~~~ to;!1 .:;-_."<-- <;::'j ---\\ Signature of parent/guardian if Age 15 to 17: (~,.... , ;::-::: -'I ~ . .:-- '- ",' ::.:': .,j NAME At'lY1Jen-4 J<haJ? Hv.IE ADDRESS 12 3 'J)~r6t'rlJ ~C:f. /~tAJt:l !:t'r!-y, 1.4- Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 3:2- OCCUPATION Lt61?:V-f ~'" / \yht.11 -{ f 7L EMPLOYER tlnill.gr~; 1 "1/ ~ cI.d~ PHONE NUMBER: HOME J;I/- =?s4-fN/~ BUSINESS 3/1-33'!>-S-lf f 9- EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ~~. . . .,J~A~ ~/1~ ~~M~~~~..n.:.: ~'J~~~~. -j;~~ ~ ?ia~ ~:ii .r ~ 71 ~~~-- ~~ /rt... ~ d6-tA.. ~ / ," ~ -. .' ZIP [B'Yes :2; .o!__ r0 ff~;). ;20 DNo Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 1 of 7 'f!~~.~_ ~.~~rf1b~ .,.9~-'~ ./~... /J --J--~. J).~, ~~.~~ , ~L1~.'- ~ ~.~. ~~~~ < ~ WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? -.D . ~~ Ci-o~~~~ ~~0la . -' ~ ~ tX-il/~~- ~~~~~~~~ .~ ~ . . F~ ~ .A~ ~ fi1A ~ ad '=1l- cd!f-~~J2~~ ~k ~ ClI.o ""-~ ~ POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory board and your personal interests,including financial interests and your duties to an employer. In particular, if you are applying to be a member of a board or commission which makes recommendations tothe C' .' ::ouncil about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). /",.~ ~o If you are uncertain whether a potential conflict of interest exists or have questions ab~tged!an 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. >:. ;'} ~T1 G' , ;:::: --',. ~- -rl ,"-'j ".1 IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? fi2rYes D No CJ1 DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? D Yes ~ (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I: I -....= -14-... ~~~;!:~ ~... "'IIIII~ ..,.... CITY OF IOWA CITY Name of City D t? /J. t1--1LUA'~__ /7. "-17:. Board/Commission/Committee V ~ jJ4 n(.A/V~' 7 U~ Name ;4~ t<~ tJ 3)tJ~J.:2CJtJ?- , f Section 362.5 of the Code of Iowa generally prohibits. with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner. or parent if applicant is Age 15 to 17, have an ownership interest (for example. sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS n. .II }( tv. ,. '/7 ~ tf) r/J n.~J "'''"0:'' q..2.j n_.-L {".:::f. I p k)&f Cd' Y ">PIP' r , /dtva 5.;1:;1'10 , 0 c:.::., C..J ~ .-::::: ~:~~ 3:':; ..' N _~_I .'--", 3C cr', ~.._, .. ;:t:-,. ;_.~-; -^._-~ ,_..", -'. .::::- ~;,..., '" .> - -- -. -::P ;:';; NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. APPlicantSignature~ ~ _ Signature of parent/guardian if Age 15 to 17: Address f1,;2? l7~ 31 ~ t:tZj , If} l:?,;li9!f {~ Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 3 of7 City of Iowa City Advisory Board/Commission/Committee _ ~pplication Form I ~ 1 -....= -1lQo ~~~!:'t ~... ,,1IlI1'- ...... .. CITY OF IOWA CITY Individuals serving on Boards/Commissions/Committees play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. This form may be filled out manually (please use a black ink pen), typewritten, or electronically (PDF). Return the application to City Clerk, 410 E. Washington St., Iowa City, Iowa. THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Youth Advisory Commission, Age on the date offiling:D Age 15 to 17 (or) GAge 18Jo 21~ , ; ilL '#?1 ( Term' Advisory Board/Commission/Committee Name '_:::1 Signature of parent/guardian if Age 15 to 17: ;<. : Ii /J_ -j \ME rMTtfc./(..; K, ;4hJU1/&r-' i: :~ HOME ADDRESS 5"/?I' ()~b/ ~ / :r (? m. ZIP 5-P'? f/O Is your home address (listed above) within the corporate limits of Iowa City? ~ Yes D No How long have you been a resident of Iowa City? //} 'Y...!!.-n- / /:l OCCUPATION .4dl"b /;.m,q-/ A..f h/13td/. EMPLOYER ?~~-..Mn/~ PHONE NUMBER: HOME 9'cs-~-3t/~Y" BUSINESS :J'57~7/h EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ~,;4. t-iA h~ FlI't3 / ~~It/€./ t:J.e~')-~.$r>?'\. /2~ ~/~~7' ptL 10 dM~zfP7~ 1'Ju..?J~/AeV ~~ H'.S.J~( 1'X~~L::::1~~#7~" .~~~~rp~( Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? . .~ /~.A/~ -:1 V;;:5~ Ue;? .' . ;; ~ t(?I z:k--- v##~~ /t:'~ rJ?J-7 ~ ~ ~ U/~-~. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ~ ~~r -hie /<<~ ~YJ~, :z: A~ , td'up1~/ /1~ ~/l~/ ~ ~~ _ #t ~?~k//1-L~~ ~az-v.nJ, 7 ..6Y~ /V/M d ~~/l~ ~ ~ ~ v/#z/ ~~/ ~~~ c:N~' POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory board and your personal interests, including financial interests and your duties to an employer. . particular, if you are applying to be a member of a board or commission which makes recommendations tothe City Council about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.50fthe Code oflowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). , .~, r--') (;5 If you are uncertain whether a potential conflict of interest exists or have questions a!)pI(!-'SeGtLon 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. ...... :"c ;;, .~ ::=J -0 11 C.~I ........ --' .:.0.- N ::',.'- . . - IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes D No C"o ...L DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? D Yes ~NO (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ I --= -~ !~<ii;!:1lt -.;;:.... .,.l1li1'- .....~ CITY OF IOWA CITY Name of City () / / II! / A / / Board/Commission/Committee IUfJ/ll:- ffrr /1-;(1//;"'1 ,o?n;rt' f MillUL IL CJ4 (2.Al E V Date .y~ ~'/ Name Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS ./H/" vllrml61_ -- d)N /00/ ./-b111LJ;/C?o,d' A/v/' ~,~ , . /' ,- '.c,' \~.1 . ...::;: ~-" """(:>0 -- ~ ,- -a -'n ',.: '.' :;::;:J ,~. , ,- :<..~,. -n \-1 -"2' -,- <J ,....-"j .<::: - 0" NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additiona//s. ~ Applicant Signature 6 ~476 ~ ~ ~ Signature of parent/guardian it Age 15)P 17: Address 574 '{)"i'.1 ~ #~ I .-;::: Ie, ~ , -5'"7 ;:z. V D Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 3 of 7 City of Iowa City Advisory Board/Commission/Committee Application Form I ~ 1 ~~~~*t '-... .....,m~ ~~ CiTY OF IOWA CiTY Individuals serving on Boards/Commissions/Committees play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. This form may be filled out manually (please use a black ink pen), typewritten, or electronically (PDF). Return the application to City Clerk, 410 E. Washington St., Iowa City, Iowa. THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURINGTHATTIME. _..... 6:1rY1(}\l5SI~pivtC5 Advisory Board/Commission/Committee Name J..)v..JC,- (L-t\ Avt Ad v15GI J Term JiGv'). 2o{) 7 Youth Advisory Commission, Age on the date of filing: D Age 15 to 17 (or) D Age 18 to 21 Signature of parenUguardian if Age 15 to 17: NAME HlU'1Cl-V d I~. FL.-LV b S HOME ADDRESS 32(0 1--+v..\-cluVlS6Y1 A-ve.. (NQ (L~ Zl~d 5 2~'-I to Is your home address (listed above) within the corporate limits of Iowa City? ~ Yes :sB] N~'; -" ~:Q How long have you been a resi ent of Iowa City? / -:) yCCt).-S ~~; ., ~ OCCUPATION h()1..-lS€UJ\ y1)~~ -,- EMPLOYER g:"~ ~T] PHONE NUMBER: HOME 3 1 331- LfSb BUSINESS ~ Si>: ;.::;'---' )> c> EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION:i.i1 2..~" '6 ~~ ~ ~ QA,1 ~ (P~\- UkUu); ~ +V'~5. / --P:'~ @ LCTM,A.Q'e, ~) CM::t :>.~ wJo fYlL.nJtv-- C i2"il~) t.f ~'. . ~& ~. ~L 5~"b Te .:1~ tIlAQM,LkA(zcr' J ~6-S ~ UT/L1C ~. J ~ (Co ~.~ . . '. . ~\.vA GVv\JlitJ\!'Ulc.tM:t .. ~ ~ CL.d ~ ~<,1.~jA.Ur-/ 6 ~ Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? L'VVli1-eJ --L 5r~ ~. I" l41!tc C~ +--~L~& c~ ~ ~ )Jk~~Clc8 ~X~~?~ , ,~U~c. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ...-rrv..-. Fe..Llvu s: ~'-1\.~..j...,;> J 'tL 1..6.X 'lM ecr1 . 1J ~'f tL4 d '[Vu ~ C)tD ~ . rcrJ. ~ Vv~ ~~ r ~ ~'.~ CtL~ ctn J~Ic, 0 J~v;~ ~ ~ (C0 Y\~ l>~~~)/ ., ~ ~5 c.<. ~ '=2 ~ (?rrv~VVU..<A..1 h -L O-v..JCc ~~ . .J. t (jlfi!I.~ jVe CU"- [..uYL6J Xc ~ ~ ~"-v\..:t. ()[...Gt vYVLWllL~1 dA ~ ",/!A J IA~ ",'to YVctLh 4 ~..v.t ~ ~r.:!/ ~~ ~ ~ I I ~ n,-,- ~~ ~ .;UVIiL :f:<J 0'YVlWUA: "Th ~~ 'CIM- L>>-t..LQ, POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory board and your personal interests, including financial interests and your duties to an employer. In particular, if you are applying to be a member of a board or commission which makes recommendations tothe City Council about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions a~ut Se~n 362.5 of the Code of Iowa, please contact the City Attorney's office at 356-5030. :< n ~ ~ -_ "- ,.l J:>o ~." il f-- ,--, :;? ; I -, .....,..--' --_...J ~ , IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes ~o a DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? D~s [BN'o (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 2 of7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ 1 ~~~~tt -..:::.... .......'- ..,..~ CiTY OF IOWA CiTY Name of City Board/Commission/Committee Name MCl.Ac,GU'e-f \ Avt AJI/\S6Y1 R. 'Fu V l GY1j c:)) Vl1 /i1. U 55~fYl Date I-f/II/O:r Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME ~ BUSINESS ADDRESS flu' \.o-vc c; t-w V\I\ S ( -\{LW\i ~ \CV'Vl'1) Nu.sc.QnVlQ. .:I:m..J"- j I , ;""~) c::.:) SJ ~ ~ ::;:; --' ':J -Il .~,_., - .~.- '.. . !-- ;';- ,:--r-, - j I '=; ':,', =.h: <) , . ..0:;;'/" r:y -, y -J NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature '}1/\. C-\.A-'~ R. Fu--v ~ Signature of parent/guardian if Age 15 to 17: Address ?;Uo \--I--1A.\-c~\I\ ~ TGwlA. rA 522 Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application December 2006 Page 30f7