HomeMy WebLinkAbout2003-10-28 AppointmentSpouses 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: 3
Females: 3
Council Announcement Date: September 9, 2003
Application Deadline: Wednesday, 5:00 p.m., October 22, 2003
Council Appointment Date: October 28, 2003
HUMAN RIGHTS COMMISSION
One Vacancy - Unexpired Terms
Ending January 1, 2005
Bob Peffer resigned
Oliver Christian Belcher []
636 S. Dodge St #6
Ron Mavrias []
464 Samoa
Mark Grover []
2874 Triple Crown Ln #7
Valerie Garr []
14 Pond View Ct
[] Denotes applicant completed the Confidential page of the application.
NOTICE
THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION:
HUMAN RIGHTS COMMISSION
One Vacancy - Unexpired Term
Ending January 1,2005
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 eliminate 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, October 22, 2003. 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 the Civic Center, 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 Heather Shank,
Human Rights Coordinator at 356~5022.
September 10, 2003
CITY OF IOWA CITY
ADVISORY BOARD/COMMISSION FILED
APPLICATION FORM ~0030CT 10 PH 3:30
CiT,' CLERK
Individuals serving on Boards/Commissions play an important role in advising the C~u~o~a~e~&terest
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 6ounoil meeting. Appointees serve as unpaid volunteers.
PLEASE USE A BLAOK INK PEN. 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 PA6E MARKED *'CONFIDENTIAL.'" THIS APPLICATION WILL
BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY
DURING THAT TIME.
ADVISORY BOARD/COMMISSION NAME ~"~UW~a.V~ ~-~t"~ ~Z)C'~Vi~{$$~ TERMJc'~tu ~' ~l ~
NAME ~ ~ ~ HOME ADDRESS ~U~.~.~
Is your home address (listed above) within the corporate limits of Iowa City? ~Yes ~ No
How long have you been a resident of Iowa City? ~ ~ ~5
PHONE NUMBER: HOME ~l~- ~5[~G~ BUSINESS ~[~'~5'~ ~
EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION:
WHAT ~S YOUR PRESENT KNOWLEDGE OF TH~S ADWSORY BOARD?
I M
isrepresentations on this application will constitute just cause for removal of an appointee.
If you fail to answer all the questions, Council will not consider your application.
cletk\atlbdcomapp( 1 ),doc April 2002
NHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR
APPLYING)? ~-¢_~,v~ ~,~ ~'~ ~¢~ {~ ~ /,~ i~o~ ~ ~ ~ ~{~
,, · ~ ' ~ ., - U t ' ,
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 to
the City Council about the allocation of City funds, please list any present affiliations you have with agencies
that 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 of the Code of Iowa generally prohibits, with certain important
exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of
Section 362.5 is attached.
,f you are unce~ain whether a potential conflict of interest exists or have questions about Section 362.5 of the
Code of Iowa, please contact the City Attorney's office at 356-5030.
IF ARE NOT SELECTEO, DO WANT TO BE NOTIFIED? NO g -
DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? YES 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 will not consider your application.
clerk\hrcornapp(1 ).doc Apdl 2002
(2)
TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY
Effective January 31, 2002
Household 30% Median Income $0% Median 60% Median 80% Median Income Median
Size (Poverty Level) Income Income (low income) Income
1 $13,600 $22,700 $27,200 $36,300 $45,400
2 15,550 25,900 31,100 41,450 51,800
3 17,500 29,150 35~000 46,650 58,300
4 19,450 32,400 38,900 51,850 64,800
5 21,000 35,000 42,000 56,000 70,000
6 22,550 37,600 45~100 60,150 75,200
7 24,1 O0 40,200 48,200 64,300 80,400
8 25,650 42~750 51,300 68,450 85,500
ATTACHMENT TO APPLICATION FOR THE
HUMAN RIGHTS COMMISSION
It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as
defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights
Commission is representative of the community. Therefore, "appointments shall take into consideration men and
women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94-3647, 11-8-94)
OPTIONAL:
PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN
CHOOSING AN APPLICANT.
'"~L~ Age Religion
Gender Disability
Income (see table) Race, color
or ethnic group
Sexual Orientation National origin
Other (Please explain below)
clerk~momapp{1).doc ~ Ap~2002
Oliver Belcher
636 South Dodge Street ~C) o 1--'
Apartment #6 -"~ ~ ~
Iowa City, IA 52240 ,.~)~::~~ (~
(319) 325-3555 ~.
EDUCATION
University of Iowa; Economics major (B.S.), Junior
EMPLOYMENT
Research Assistant, UI French and Italian Department: Iowa City, IA
Research for materials associated with a French professor's IWendelin
Guentner) book project. Proofread and revise manuscripts of the book.
(August 2003 - June 2004)
Deli Staff/Cashier, New Pioneer Cooperative Society: Iowa City, IA
Preparing customer arders, general upkeep of the working area, handling
deposits when counting down cashier drawer, and answering phones.
(May 2002 - March 2003)
Cashier/Staff, The Main Squeeze Juice Bar: Grinnell, IA
Made smoothie and specialty drinks in unique small town environment,
trusted by owner to close stare alone, cleaned customer and employee
areas. (August 2001 - December 2001}
REFERENCES
Steven Kanner, City Councilor, (319) 338-8865
Shelton Stromquist, History Department, Professor (319) 337-5463
Reza Asian, Religion Department, Visiting Professor (805) 698-9122
OTHER EXPERIENCE & INTERESTS
Human Rights Charter Cornmiffee, University of Iowa: research inquiries
and propose solutions on local human rights issues, mostly regarding the
University of Iowa. (September 2003 - May 2004)
DJ/Commentator ICDIC, Grinnell College Radio: research local, national,
and international issues and relate to the public; play specific: music
format. (August 2001- December 2001)
Poweshiek County Green Party, Chairman: registered voters for the Green
Party, set up "green" events, and coordinated sponsorship for local
activities in Poweshiek County, Iowa. (February 2001 - December 2001)
PUBLICATIONS
"Bitter Coffee Market Realities" Fellowship Vol. 69, Issue 5 (July/Aug. 2003).
CITY OF IOWA CITY
ADVISORY BOARD/COMMISSION
A, PPLICATION FORM
Individuals serVing on Boards/Commissions play an important mia in advising the Council on matters of interest to our
community and its futura. Applicants must reside in Iowa City.
After a vacancy has been announced, the Council reviews all applications dudng the work session. The appointment
is made at the next formal Council meeting. Appointees serve as unpaid volunteers.
PLEASE USE A BLACK INK PEN. 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY
DURING THAT TIME.
[
^DV,SORY BOARD/COMMiSSiON NAME~.~. ~ ~.~
NAME~/~ ~ /~.,~,r//~/,~r_~ HOME ADDRESS ~'$/-/:.~z,, ~--~ ~. __'-t-I
Is your home address (listed above) within the corporate limits of Iowa City? ~ Yes --o
How long have you been a resi'dent of Iowa City?. ~'2 ~,~3.-
OCCUPATION ,'~,~.r'~.~.,~ ~,~ EMPLOYER ~//~'~"
I- ,.)NE NUMBER: Hor,;1E ,.~j~'";~',~? BUSINESS
EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ~
WHA~,~ YO~. ~.~S~N~ KNOW~ O~.H,S A~V,SO.Y ~OA.~ ~ ~~ ~
Misrepresentations on this application will constitute just cause for removal of an appointee.
If you fail to answer all the questions, Council will not consider your application.
cclerk\bdcomapp( 1).doc April 2002
W'qAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR
POTENTIAL CONFLICTS OF INTEREST
Please identi~ any potential ~nflicts be~een membership on the adviso~ board and your personal interests,
including financial interests and your duties to an employer.
In pa~icular, if you are applying to be a member of a board or ~mmission which makes re~mmendations to the
Ci~ Council about the allo~tion of Ci~ funds, please list any present a~liations you have with agencies that apply
for funding from the City. "A~liation" includes being a board member or employee of the agency. Other types of
a~liations must be examined on a case by case basis by the City A~orney's o~ce.
You should also know that Section 362.5 of the Code of Iowa generally prohibit, with ~ain impodant exceptions, a
member of a ci~ Board or Commission from having an interest in a ci~ ~ntract. A ~py of Section 362.5 is
attached.
~ ~u are unce~ain whether a potential ~nflict of interest exists or have questions about Section 362.5 of the Code
of Iowa, please conta~ the City A~orney's o~ce at 356-5030. ~ ~
/ / ~ ~ ~
0~ ~ ~ ,
--
IF YOU ARE NOT SELECTED. DO YOU WANT TO BE NOTIFIED? ,X' YES NO
DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? YES .X NO
(It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.)
If you fail to answer all the questions, Council will not consider your application.
cclerk\bdcornapp(l ).doc April 2002
(2)
TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY
Effective January 31, 2002
Household 30% Median Income 50% Median 60% Median 80% Median Income Median
Size (Poverty Level) Income Income (low income) Income
! $13,600 $22,700 $27,200 $36,300 $45,400
2 15,550 25,900 31, ! 00 41,450 51,800
3 17,500 29,150 35,000 46,650 58,300
4 19,450 32,400 38,900 51,850 64,800
5 21,000 35,000 42,000 56,000 70,000
6 22,550 37,600 45,100 60,150 75,200
7 24,100 40,200 48,200 64,300 80,400
8 25,650 42,750 51,300 68,450 85,500
ATTACHMENT TO APPLICATION FOR THE
HUMAN RIGHTS COMMISSION
It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination
as defined in the Human Rights Ordinance. In order to further this goal, the city sa-ives to ensure that the
Human Rights Commission is representative of the community. Therefore, "appointments shall take into
consideration men and women of various racial, religious, cultural, social and economic groups in the city."
(Ord. 94-3647, 11-8-94)
OPTIONAL:
PLEASE PROVIDE ADDITIONAL INFORMATION ]FOR THE COUNCIL TO CONSIDER WHEN
CHOOSING AN APPLICANT.
Age ~ Religion
Gender ~ Disability
Income (see table) ~ Race, color
or ethnic group
8exual Orientation . National origin
Other (Please explain below)
Human Rights Attachment.doc April 2002
CITY OF IOWA CITY
ADVISORY BOARD/COMMISSION
.APPLICATION FORM
Individuals serving on Boards/Commissions 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 ~olunteers.
PLEASE USE A BLACK INK PEN. 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY
DURING THAT TIME.
ADVISORY BOARD/COMMISSION NAME /LJ'~P,4,~ ~,'~'/~_,' ~,r~,,~,'c£,'~, TERM
NAME //V~.~.~J~ ~VE~ HOME ADDRESS ~'~'/'~~'~ /"~'~D/~ Croud~
I
Is your home address (listed above) within the corporate limits of Iowa City? ~,Yes No
How long have you been a resident of Iowa City?. ~ ~'
OCCUPATION /~./~ 7F/~ ,~e,.<:-//~/~'L( orf'..~yo~t...EMPLOYER ~//~,,ve-r-$.~/-'~:::eo
~ DNENUMBER: HOME ~i~- 3~- ]3~$ BUSINESS 31~
ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSIT~I~
EXPERIENCE
AND/OR
WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD?
I - I
Mismpmsontations on this application will constituto just causo for romoval of an appointoe.
If you fail to answor all tho quostions, Council will not considor your application.
ccterk\bdcomapp( 1),dcc Apdl 2002
(~)
W4AT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR
APPLYING)?
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 to the
City Council about the allocation of City funds, please list any present affiliations you have with agencies that 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 of the Code of Iowa generally prohibits, with certain important exceptions, a
member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is
attached.
I ~u are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of the Code
of Iowa, please contact the City Attorney's office at 356-5030.
/ V o ,, Fl,,,~ -Z- ,
~ l-r~ "o
IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~YES NO
DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? YES ANO
(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.
!f you fail to answer all the questions, Council will not consider your application.
cclerk'~)dcomapp(l ).dec April 2002
(2)
TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY
Effective January 31, 2002
Household 30% Median Income 50% Median 60% Median 80% Median Income Median
Size (Poverty Level) Income Income (low income) Income
1 $13,600 $22,700 $27,200 $36,300 $45,400
2 15,550 25,900 31,100 41,450 51,800
3 17,500 29,150 35,000 46,650 58,300
4 19,450 32,400 38,900 51,850 64,800
5 21,000 35,000 42,000 56,000 70,000
6 22,550 37,600 45,100 60,150 75,200
7 24,100 40,200 48,200 64,300 80,400
8 25,650 42,750 51,300 68,450 85,500
ATTACHMENT TO APPLICATION FOR TIlE
HUMAN RIGHTS COMMISSION
It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination
as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the
Human Rights Commission is representative of the community. Therefore, "appointments shall take into
consideration men and women of various racial, religious, cultural, social and economic groups in the city."
(Ord. 94-3647, 11-8-94)
OPTIONAL:
PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN
CHOOSING AN APPLICANT.
Age ~£,'~co/o,-- [ Religion
Gender Disability
,~ ~/~ 0 0 Income (see table) Race, color
or ethnic group
Sexual Orientation National origin
Other (Please explain below) ~ ~
Human Rights Attachment. doe April 2002
CITY OF IOWA CITY
ADVISORY BOARD/COMMISSION
.PPLICATION FORM
Individuals serving on Boards/Commissions 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.
PLEASE USE A BLACK INK PEN. 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
BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY
DURING THAT TIME.
ADVISORY BOARD/COMMISSION NAME /G~o~f/~ ~ (l'P';P'~Z.'ZZzi,5,El~e'~ TERM ~
NAME /~ ~ HOME ADDRESS /~ ~
Is your home address {listed above) within the corporate limits of Iowa City? ~ Yes ~ ~ N~ ~
How long have you been a resident of Iowa City? J~/~ /~7~ .~ ~ ~
~CUPATION :~,~,~"~'~-~'~'~ EMPLOYER ~,~.~, ~
PHONENUM.E.: HOME 3m) .US,NESS (?m)
EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 5/~. ,~2~/~f-,~:
I / ~ ~,~
WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD7 ~ ~,~,~-~
Misrepresentations on this application will constitute just cause for removal of an appointee. ~
I
If you fail to answer all the questions, Council will not consider your application.
cler k~all~comapp( 1 ).d~ April 2002
WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR
. PLYING)? I) ~/~-~-~ ~J~/~,~'/~ ~'~/'~'/,~_ ,z~ ~ ~ ~ ~ ~(~,~ {5~
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 to
the City Council about the allocation of City funds, please list any present affiliations you have with agencies
that 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 of the Code of Iowa generally prohibits, with certain important
exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of
Section 362.5 is attached.
~ou are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of the
(Jode of Iowa, please contact the City Attorney's office at 356-5030.
IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED?''~YES NO~/'
DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? ~YES ~NO
(It has been Council policy not to permit an individual to se~e 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 will not consider your application.
cie rl~hrcoma pp( 1).doc Apd12002
(2)
TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY
Effective January 31, 2002
Household 30% Median Income 50% Median 60% Median 80% Median Income Median
Size (Poverty Level) Income Income (Iow income) Income
1 $13,600 $22,700 $27,200 $36,300 $45,400
2 15,550 25,900 31,100 41,450 51,800
3 17,500 29,150 35,000 46,650 58,300
4 19,450 32,400 38,900 51,850 64,800
5 21,000 35,000 42,000 56,000 70,000
6 22,550 37,600 45,100 60,150 75,200
7 24,100 40,200 48,200 64,300 80,400
8 25,650 42,750 51,300 68,450 85,500
ATTACHMENT TO APPLICATION FOR THE
HUMAN RIGHTS COMMISSION
It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as
defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights
Commission is representative of the community. Therefore, "appointments shall take into consideration men and
wome~ of various racial, religious, cultural, social and economic groups in the city." (Ord. 94-3647, 11-8-94)
OPTIONAL:
PLEASE PROVIDE ADDITIONAL INFORMATION FOR TIlE COUNCIL TO CONSIDER WHEN
CHOOSING AN APPLICANT.
~/~ Age /)a ~/,~- Religion
~f-C Gender ~ Na DisabiliW
~ ~ ~eome (see ~ble) ./~,~ ~ce, color
or e~c ~oup
[~a~/ Sexu~ Orientation [~ 5 ..~. Na~on~ ofig~
O~er (Please expl~ below) ~ ~ ~
~mm~l'~ ~fi12002