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HomeMy WebLinkAbout2009-11-02 Appointment22a NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: AIRPORT ZONING COMMISSION One vacancy -Six-yr Term January 1, 2010 -December 31, 2015 Duties of the Airport Zoning Commission are: 1. To recommend amendments to the current Iowa City Airport Zoning regulations, including the repeal thereof. 2. To recommend the adoption of new Airport Zoning regulations. Iowa City-appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets as required. Applications must be received by 5:00 p.m., Wednesday, October 28, 2009. 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 Airport Zoning Commission should be directed to Michael Tharp, Airport Operations Specialist at 356-5045. 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: 1 Council Announcement Date: September 15, 2009 Application Deadline: Wednesday, 5:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 AIRPORT ZONING COMMISSION One Vacancy -Six-year Term January 1, 2010 -December 31, 2015 Term expires for Brian Sponcil No applications as of Wednesday, 5:OOp.m., October 28, 2009 D Denotes applicant completed the Confidential page of the application. 22b NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: BOARD OF APPEALS One Vacancy- Five-Year Term January 1, 2010 -December 31, 2014 One (1) Building Design Professional It is the duty of members of the Board of Appeals to hold appeal hearings on matters concerning the Uniform Building Code, Uniform Plumbing Code, National Electric Code, Uniform Mechanical Code, Uniform Fire Code, the Dangerous Building Code, and the Iowa City Housing Code. Members must be qualified by experience and training to pass upon matters pertaining to building construction. Iowa City appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets the first Monday of each month at 4:30 p.m. or at the call of the Building Official. Applications must be received by 5:00 p.m., Wednesday, October 28, 2009. 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 regarding the Board of Appeals should be directed to Tim Hennes, Sr Building Inspector at 356-5122. 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: 4 Females: Council Announcement Date: September 15, 2009 Application Deadline: Wednesday, S:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 BOARD OF APPEALS One vacancy -Five-year Term (1) Building Design Professional January 1, 2010 -December 31, 2014 Term expires for Stephen Buckman No applications as of Wednesday, S:OOp.m., October 28, 2009 D Denotes applicant completed the Confidential page of the application. 22c NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: HUMAN RIGHTS COMMISSION Three Vacancies -Three-Year Terms January 1, 2010 -January 1, 2013 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 28, 2009. 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. Human R%gh s Commission August 18, 2009 Page 2 of 2 Hum~r~ fight Commission ATTENDANCE RECORD 2009 /Meeting Date) NAME TERM EXP. 1/27 2/24 3/24 4/21 5/19 6/16 7/21 8/18 9/15 10/20 11117 12/15 Newman Abuissa 1/1/10 X X X X X O X O O Kelli Shireen- Fleming 1/1/10 - - - - - O X X X Eric Kusiak 1/1/10 O X X X X X X X O Dell Briggs 1/1111 X X X X O X X X X Yolanda Spears 111/11 X X X O X X O O X Corey Stoglin 1/1/11 O O O O O O O X X Dianne Day 1/1/12 X X X X X X X X X Wangui Gathua 111112 X X X X X O P O X Martha Lubaroff 1/1/12 O X X O O X X O X Joy Kross 1/1/10 O O R R R R R R R KEY: X = Present O = Absent O/E = Absent/Excused NM = No meeting/No Quorum R =Resigned - = Not a Member 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: 4 Council Announcement Date: September 15, 2009 Application Deadline: Wednesday, S:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 HUMAN RIGHTS COMMISSION Three Vacancies -Three-year Terms January 1, 2010 -January 1, 2013 Term expires for Kelli Fleming, Eric Kusiak, Newman Abuissa Libris Fidelis ~ 320 S Dubuque St Jill Schnoebelen ~ 2422 Lakeside Dr #10 Rita Offutt ~ 2704 Brookside Dr Fernando Mena-Carrasco D 207 Myrtle Ave Apt #6 Amos Petersen ~ 424 E Jefferson #3 Michelle Falkoff ~ 922 Church St Mary Therese Maher Sturm D 800 Eastmoor Dr Constance Goeb Cuttell ~ 145 Oakridge Ave Dr Howard Cowen ~ 2664 Triple Crown Ln #5 Dan Tallon ~ 320 S Gilbert St Debra (Deb) A. Derksen D 3645 Rohret Rd Richard Twohy D 319 E Washington St Kelsey Miller ~ 100 Daum #5301 ~ Denotes applicant completed the Confidential page of the application. City of Iowa City _ ~ r 1 ' o Board/Commission/Committee ~ ~.`II ~~`; '~ Advis ry ~~ ~ .application Form 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name f~l;~~~i~ jZtC'~r~ Term ~ ifr~i~~ 2G.lC° _ ~ NAME ~f~Fr1S FrG~~IiS HOME ADDRESS ~ ~• ~ Scx1`tN ~ ~' ~v'C~t,~~~ ~~tt~>e~ ~" ~~~~ Ctlr~ ;~ci.~~ ZIP ~ 1 `2 ~'~ ~-- Is your home address (listed above) within the corporate limits of Iowa City? Yes aNo How long have you been a resident of Iowa City? ~ ~~.~ s NII~i1L 'i'C l~.Lt~ .~3QX •~~~ :~'eut2.. C`ch~ ~~cq~~ ~Z,~~ MPLOYER OCCUPATION Ir'~•~l~t c~ 4 r'HONE NUMBER: HOME BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: .:[ Ii~i~ I~~jy r~S le ~ ~~~ ~~~~ttc~~Ptc lid iM C'111i ~ 6~~~~~r iS fr~s` .-~- u~l~ a-~~° z, ~b',~L~'~-~' c'1~ ~ cr~'~~fvis~ r ,:; ~.._ _-, ,,,,) . :-"+~ :,.> ~niunT Ic vn11R PRFRFNT KNr~WI Ff)C;F nF THIS ADVISORY BOARD? ~'`~ ~ ~~ ~ ~ 2. ~~~~~ Ih'1~~ ~n~~ 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYINGI? ~;~ ~. •~`2rr~ z~cf4 Gto-~~s~- ?.l r' ~~is~/ ~i~ ~IC~~rLIZ~f Ci V~ ~ ~~y~t`~s ~~ t~ ZiPP/i~s''0f S S/ e~.sa, C,' 4~ 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 *hat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. ether 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 (see page 71. - - -~ ,. ; If you are uncertain whether a potential conflict of interest exists or have questions about-.Section 3625 of the Code 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 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. Human Rights Commission Application March 2008 Page 2 of 8 ~ r 1 ~;~~~~ ~ ~~,~~ BOARD, COMMISSION, & COMMITTEES -„~ ... BUSINESS LISTING CITY OF IOWA CITY Name of City ZIP 1fp~; Board/Commission/Committee ~~`~~~ ~`~~~-~ Date~~~~ Name L~yt!`s ~Ft~ij 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 (see page 71. List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS ~ev ova .0. Ba13 t ~ Ewa ~ ~ 5'2~¢~ f,. ,- ., -. ~o .:; . -~_ ~A NOTE: Anew form must be completed if the above information changes or an ownership interest is acquired in an additional business. h Signature ~ / r~,,; ~ ~~~ >~. Address ~v, ~dX '~:~ ~~G' _- ~l.n~r~ C.i.~~,j ~c>>leU7~. ~~~~ ~~ 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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective March 19, 2009 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,950 $26,600 $31,920 $42,550 $53,200 2 18,250 30,400 36,480 48,650 60,800 3 20,500 34,200 41,040 54,700 68,400 4 22,800 38,000 45,600 60,800 76,000 5 24,600 41,050 49,260 65,650 82,100 6 26,450 44,100 52,920 70,550 88,200 7 28,250 47,100 56,520 75,400 94,200 g 30,100 50,150 60,180 80,250 100 300 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 thrs =goal, ~~e city°io strives to ensure that the Human Rights Commission is representative of the 'commaunit Therefore, "appointments shall take into consideration men and women of _ various ~_~.raciah.~ religious, cultural, social and economic groups in the city." (Ord. 94-3647, 1 1-8-941;: __ ' ' .:-W OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. (C ~ Age y1~ ~ Religion ~,(~` Gender ~~ ~a0 , ~~,~ Income (see table) ~~~, . ~~ Sexual Orientation Other (Please explain below) -~y~~Ft~,~ Disability Race, color c'~'2c1c~~ rj ~ 4~ or ethnic group (~S~ National origin Human Rights Commission Application March 2008 Page 4 of 8 City of Iowa City ' r ~_._.®~ Adviso Board/Commission/Committee ~.`I°,~`~ rY ..~..~ ~-pplication Form 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission Term 3 years NAME Rita Offutt HOME ADDRESS 2704 Brookside Drive Iowa City, IA Is your home address (listed above) within the corporate limits of Iowa City? /~ Yes How long have you been a resident of Iowa City? 15 years OCCUPATION Case Manager rHONE NUMBER ZIP 52245 DNO , _, -:_:~ ~~ _' ~ i ___{ ~., r ]'ii 1 . , f.., ~ ~ '-~ ~ , s EMPLOYER Shelter House BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION I spent my life advocating for people that experience discrimination due to mental illness, limited education and economic status. I strongly believe in human rights and believe my experiences will contribute to the committee. I received a Human Rights Award from City of Iowa City in 2003. I work as case manager and advocate at Shelter House. I presently volunteer at NAMI-JC as a teacher for the family to family class. I was the former Director and have been board member of NAMI-JC. I presently am on the council for the Homeless Children's Trust. I have worked with Human Rights Council as a volunteer for the Building Block Program. I have worked in New York City as a recreation therapist in inner city hospital in the South Bronx and started a successful youth program hiring inner city high school students to work with the children at the hospital in the summer and after school. I worked as a counselor in a housing and employment program for adults with mental illness at Fountain House in New York. I love to organize musical events and programs to raise awareness for Human Rights causes. I am a member of the world music group Kol-Shiva and we perform for Compeer, NAMI, Crisis Center, Homeless Children's Trust and Diversity Fairs. ~~,~,~-~- is vni io ouGCGnrr Knirnn/I Fr)r;F nF THIS ADVISORY BOARD? I have volunteered for the Building Blocks Program. I have nominated people for Human Rights awards and annually attend the Human Rights Breakfast but other then that I do not know how advisory board is organized and operates. 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. HOME (319) 351-4377 Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR ^ °PLYING-? understand and love the Iowa City Community and am familiar with its services, resources and problems. I feel that the City has made me and my family feel welcome. I want to give back. Next year my eldest son Sam will be in college and his brother James will be out of the country as a foreign exchange student. I will have time to volunteer for the things that matter to me. have a strong commitment to work with the City to help continue the tradition of fostering Human Rights to its residents. I believe that my experience, passion and commitment for Human Rights for afl can help the City promote creative programs and solutions to deal with the difficult and challenging human rights issues facing Iowa City. 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 +hat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. _her 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 (see page 7). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of the ~,,.~o of Inwa nlaase contact the City Attornev's office at 356-5030. `~' vv.+.. .~. .-.. , r.__.__ - _. - Shelter House ~ _~ Homeless Children's Trust affiliated with HACAP ~~ past employee and board member of NAMI-JC .~ fH, ~` r ,,~ 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 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. Human Rights Commission Application March 2008 Page 2 of 8 10-16-'09 15;47 FF30M-SHELTER HOUSE 319-358-7132 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committoa Muman Rights Commision Name Rita Offutt T-937 P002/002 F-397 1 ~` 1 ~~~i ~~~ ~~~q~ -•a~ CrtY OF 101NA CITY Date 10/18/2009 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership in#erest (for example, sole proprietor, partner, 5% or more of corporation`s stockholdings). Please indicate if there ar® Wane. BUSINESS NAME BUSINESS ADDRESS none ~~~ ~ ~~ t~rr ic;va Cif-, [owa y'- completed if NOTE: Anew form m is acquired in Signature Address 2704 Brookside Drive Iowa Misrepr®sgntations on this application will constitute just cause for removal of an appointee. I'~ If you fail to answer all the questions, Council may not consider your application. IA 52245 changes or an ownership interest Human Rights Commission Application March 20x8 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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, 1 1-8-94) OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 55 qge Jewish Religion female Gender ~ Disability 39,000 Income (see table) Race, color white or ethnic group Sexual Orientation a Other (Please explain below) National origin 5`- s ~r~ 1 6 ~n~~ P!: Human Rights Commission Application ` ~ ~`"' ` ~"' March 2008 Page 4 of 8 ~,y-~:~~ City of Iowa City ~ r ~ ~~.:.® Adviso Board/Commission/Committee ~.`~°.~'~ . _Aplication Form cl~ o 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission Term 2010-2013 NAME Fernando R. Mena-Carrasco HOME ADDRESS 207 Myrtle Ave. Apt. # 6 Is your home address (listed above) within the corporate limits of Iowa City? ~/ Yes How long have you been a resident of Iowa City? Since December, 2004 OCCUPATION Student/Case Manager/Advocate I .JNE NUMBER HOME (319) 325-5458 ZIP 52240 ~No EMPLOYER Crisis Center :_l _~ ~ . BUSINESS 351-2726 il('T 16 7009 c~« cL;x r~ .•n ••~• • v~l I rrrl nl I A I IGV vlll 1 C(1D TLlIC DlICITIlI AI• 'C'rrd ~1[}', (pµ"d Gllr"CIIICIVVC /11VV/vn /'11,1IV1 I Iw vv• nv~ • • vv ~~~ ......~.~•• -.--~ --• • ••- Due to my future career goals and interests, I have held two positions in which I have been in charge of advocating on behalf of disadvantaged individuals and groups. Firstly, as a community support specialist for ResCare, Inc. in Muscatine, IA (3 years). While working toward my degree in social work and political science at the UI, I worked with people who had severe mental and physical disabilities, and could not live on their own. At ResCare, my duties consisted of helping them to progressively be re-integrated in social functions and daily routines -- to help advance their interest as individuals. In other words, based on one-on-one interventions, my goal was to empower them as individuals to indirectly encourage them to actively participate in society. Secondly, I have had the privilege to work at the Crisis Center as a Flood Case Advocate. While working at the Center, I have been exposed to numerous layers of the human service field. In other words, not only have I provided thorough case management and political representation to people who were severely affected by the flood, but I have also provided short- and long-term case management to food bank clients with specific needs. While I have advocated on behalf of an eclectic group of clients, my emphasis is in improving relations with the fast-growing Latin American population. ~niunr IS vni ~R PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? My understanding of the Commission is that it plays an important role in investigating discrimination allegations and enforcing Iowa City's Human Rights Ordinance. Ever since I lived in Iowa City, I have been socialized to believe in the efficacy and impartiality the Commission embraces. While I have never worked directly with the Commission, I have informally and formally referred people who feel their Human Rights are being violated or disregarded (in the form of covert or overt discrimination). 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYINGI? ~..e to my training in social work and exposure to the human service field, I have developed awell-rounded understanding of the realities traditionally underrepresented individuals (and groups) face due to numerous environmental factors. I have directly worked with people seeking supplemental assistance from the Crisis Center, and have heard and sensed what is like to have a family of seven and not be able to provide for all of them -- even with two full-time, minimum wage jobs. I have directly worked with illegal Latin American immigrants who are repeatedly abused by their landlords and employers simply because of their legal status. I am a member of a traditionally disadvantaged group, and could potentially help in connecting with Latinas'(os) mentality, culture, and reality. I am proficient in Spanish and English. I have been known for being highly involved in the work I engage in, especially if it involved investigating injustices committed against under- or unprotected groups. It is precisely due to this that I feel I could: 1) further advance the interest of those traditionally disadvantaged groups in our town, 2) be an effective connection with the Latin American population, 3) provide comprehensive and meaningful investigations in the case of alleged ~Idiscrimination and, 4) help fully embrace and protect the diversity of our town. 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. ,er 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 (see page 7). If you 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. I am a temporary employee of the Crisis Center -- with a salary currently funded by the State of Iowa Rebuild Iowa Office. ~.~~-~- , OCT 16 ~nnq at`•••' C - IF YOU ARE NU I StLt(; t tU, UV YUU VvHly I ~ v ac rvv i iriw: ~~/~ Y ca ~Jwv ~,Q-~ DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? YES ~ NO Ilt has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Human Rights Commission Name Fernando R. Mena-Carrasco r~~.~®a~ ~III~~~ -•..as._ CITY OF IOWA CITY Date 10/16/2009 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none . BUSINESS NAME BUSINESS ADDRESS ~N _ _. OCT 1 6 ~~II~q C~' % W'r' L-I ; .5.5P NOTE: Anew form must be completed if the above information changes or an ownership interest is acquired in an additional business Signature ~°-~p ~ ,~ Address 207 Myrtle Ave. Apt. # 6 wna~~.r~vvv~.~... ~.... ... .... _. .._ °r r.___. _-_-- If .,.,i ~ fail to ancwPr all the questions. Council may not consider your application. ~~ Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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, 1 1-8-94) OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 22 Age None Religion Male Gender Able-Bodied Disability 16,224 Income (see table) Race, color Chilean-American (Latino) or ethnic group Gay Sexual Orientation n Other (Please explain below) U.S.-Chile National origin OCT ~ 6 ,~na Human Rights Commission Application ~ ~' 4 '` ~- March 2008 Page 4 of 8 ~-f : 5S~ City of Iowa City r ~ ~~® 1 Advisory Board/Commission/Committee ~~`I"~,~'~ .•~...~ 'application Form CITY OF IOWA CITY Individuals searing 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission Term 2010 - 2013 NAME Amos Petersen HOME ADDRESS 424 E Jefferson, #3, Iowa City, IA 52245 ZIP 52245 Is your home address (listed above) within the corporate 1'rmits of Iowa C'rty? Q/ Yes aNo How long have you been a resident of Iowa City? 12 Years OCCUPATION Business Owner / Investor I Student ''HONE NUMBER: HOME (319) 936-3309 EMPLOYER Self-employed BUSINESS EXPERIENCE ANDlOR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I have been interested in human rights issues from a young age, when my grandmother, who is of Native American heritage, would take me to local pow-wows to help her sell her jewelry. At the pow-wows (which were more like cultural expositions than pow-wows in the traditional sense of the word), I was fortunate enough to encounter a way of life that was wholly unlike my own; I teamed the histories of cultures that did not always run parallel to mine and, finally, to appreciate those differences which have sometimes been at the root of the frustrated ambitions of many native peoples. I spent some time in Europe, and when I returned Iowa City, I started a business selling crepes in the pedestrian mall. h was then that I became acquainted with my would-be business partner, who I. am now proud to call a good friend, and through my association with him that 1 became aware of some of the shameful prejudices that continue to color our perceptions of "outsiders." Hicham is Moroccan, and during our acquaintance of the past few years, I have been made pmry to,an ugliness that still pervades our society, even in a ciiy as pleasant and cosmopolitan as ours. 1 want to work to stop this., u~un-r ~c vn~ ~R PRGCFNT KN(1WI Fll(;F (1F THIS AnVISORY BOARD? - l only know that what I have read, namely that the commission: ; - handles issues relating to discriminatory practices and policies ~ -~ " " -facilitates communication between individuals and groups °' - has a quasi judicial function in the human rights complaint process. ~ ';-~ ~~ ~r isE eprese; ~tatiuns o:: this application wit! constitute just cause for removal of an appointee. ~~ ~~ If you fail to answer ail the ttuestions, t;ouncii may not consider your appiication. ~iurnan ~;igi~ts A.om:~:issior: ~ppiication t- ~1f~f1e1 A ~ F r°. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD tOR STATE REASON FOR APPLYING}? I am awell-rounded individual who brings a wealth of experiences and a profound capacity for critical thinking and judiciousness. My past has given me a greater appreciation of the value of basic human rights than I might otherwise have had and has made me a dedicated and tenacious advocate of universal equality. - As a local businessperson and student of Economics, I have a unique understanding of the deleterious effects that discrimination can have on a community -both in terms of social detriment and the negative effects on local production possibilities. - I have a background in teaching (English as a second language} that has given me good practice in the art of communicating novel concepts. - I have a talent for mediating disputes and facilitating communication between disagreeing persons that would seem to complement the work required of the commission. POTENTIAL CONFLICTS OF INTEREST `~ ~` = -~_a ..., Please identify any potential conflicts between membership on the advisory board and your personal interests, including financial interests and your duties to an employer. a ~) In particular, if you are applying to be a member of a board or commission which makes ~d'imm'elaidations to the City Council about the allocation of City funds, please list any present affiliations yorr~iave `^~~ .'Ili 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 iawa 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 (see page 7}. If you 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. I can't foresee any immediate conflicts of interest, taut, in the interest of fug disc sure: - Ownership interest in LaVallee's Crepes, a cxirrent Iowa City Plaza mobile vending permit-holder. - CEO and majority owner of subEpsilon Media, Inc., a startup online social media company headquartered in Iowa City. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~f YES ~NO DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY 80ARD OR COMMISSION? YES ~ NO (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.} i~~iiVrepresen.atier-±s ed3 this application will constitute just cause fior removal of an appointee. ...~ ~ Y .,.., BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City BOard/COmmiSSlort/COmmlttee Human Rights Commission Name Amos Petersen ~ r :.~®~x,~ CITY OF IOWA CITY Date 10!15/2009 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS LaVallee's Crepes 783 Hwy 1 W, Suite #2, Iowa City, IA subEpsilon Media, Inc. 424 E Jefferson, #3, Iowa City, IA 52245 ,,..~ k, NOTE: Anew form must be c is acquired in an addi~i y. /!'. Signature_~_ leted if the above information changes or an ownership interest business. Address 424 E Jefferson, #3, Iowa City, IA 52245 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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income iPoverty Level! 5096 Median Income 60% Median Income 80% Median Income (low income! Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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, to city strives to ensure that the Human Rights Commission is representative of tEae comrZiunity. Therefore, "appointments shall take into consideration men and women of various.~raciaf, religious, cultural, social and economic groups in the city." (Ord. 94-3647, 11-8-94) ~:; t~ OPTIONAL: • PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 31 qge Nondenominational Christian Religion Male Gender None Disability 50% Income (see table) Straight Sexual Orientation Other (Please explain below} Race, color or ethnic group US National origin 'uman Rights Commission Application March 2008 Page 4 of 8 City of Iowa City ~ r 1 ~...:.®~ ' Board/Commission/Committee ~•`I' ,~'~ Advisory ~~ application Form 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission Term 2010-2013 NAME Michelle Falkoff HOME ADDRESS 922 Church St. Is your home address (listed above) within the corporate limits of Iowa City? ~ Yes How long have you been a resident of Iowa City? Seven years OCCUPATION Lecturer rHONE NUMBER: HOME (319) 621-1850 ZIP ~No EMPLOYER University of Iowa College of Law BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Before moving to Iowa City I practiced law in California, where I participated in several pro bono projects, including helping refugees from political persecution in EI Salvador and Guatemala obtain asylum in Texas and assisting in the writing and filing of an amicus brief before the Supreme Court on the issue of ensuring the continuation of Miranda rights. In law school I received a fellowship from the Public Interest Law Foundation, worked with the American Indian Law Alliance, and co-founded the Student Legal Action Network. While I teach Legal Analysis, Writing, and Research, I have a personal interest in constitutional law, particularly in the area of equal protection. I will also be serving as an interim board member for the University of Iowa Center for Human Rights this semester, while one of the law faculty board members is away. All of these experiences deal with issues of fairness and justice, which I hope will provide a useful framework from which to approach the Commission's work. ~~~~~T ~~ vni iR pRGCnnrr Knirnnn Fn~F nF THIS ADVISORY BOARD? VYI 1/"11 Iv Ivv.~ .. ...... .. ~~~~_ _. ...._ _._ __- I am not personally acquainted with any of the members of the Commission. I have some knowledge of the work the Commission does, though part of my decision to apply is based on my desire to learn more in anon-abstract, more hands-on fashion. 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. Human Rights Commission Application March 2008 Page 1 of 8 '-' _ ,.: ~. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD IOR STATE REASON FOR " pPLYINGI? I have two main reasons for applying to be a member of the Commission: a general interest in human rights work and a specific interest in getting more involved in the local human rights community, as well as the Iowa City community in a broader sense. I moved to Iowa over seven years ago to attend the Writers' Workshop, and my original plan was to stay for my degree and !perhaps one more year to finish a writing project, and then move on to the next phase of my life. Instead, I found a job I loved working at the law school, and over a year ago I bought a house and committed myself to the community. The challenge for me is how to be of service to more than just my students and my school. In legal practice, it wasn't difficult to find areas in which to be of use--I was a member of the California bar, and opportunities for using my law degree to assist others abounded. While in graduate school I found myself putting service on hold, trusting that I would find different opportunities once I figured out what kind of work I would do afterward. Discovering a new profession has been exciting but time-consuming, and succeeding in a new job meant focusing on work to the exclusion of just about everything else. Now that I have some more experience, I am anxious to find ways to give something back to the community I have come to love. I hope that I will be able to contribute enthusiasm and a desire to learn more about the Commission's work. I did note that the Commission does not presently contain representatives from the law school or larger legal community, so I hope to be able to build on what have historically been very strong connections in those areas, as well as help develop connections with the community of writers that Iowa City supports so well. Thank you for your consideration. 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 `tiat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Cher 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 (see page 7). If you 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. 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 (lt 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. Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Human Rights Commission Name Michelle Falkoff 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest Ifor example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none . st ~ "m~`'~~ A ~®1~~ CITY OF IOWA CITY Date 10/22/2009 Signature Address 922 Church St. Misrepresentations on this application will constitute just cause for removal of an a~~ointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application March 2008 Page 3 of 8 v is /a/pcqu/i/r~//ed~i/n/a~n~ add/i/t^/~i/o///-nal business. ' 1 / I // V / / W w / I / / .. .. _. ~ , TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21, 800 36, 300 43, 560 58,100 72, 600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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. 36 qge Jewish Religion Female Gender -~ Disability Income (see table) Race, color or ethnic group Sexual Orientation Other (Please explain below) National origin ., Human Rights Commission Application March 2008 Page 4 of 8 City of Iowa City _ ~ r ~ Adviso Board/Commission/Committee ~~ ~,~'`~`~ Application Form cl-.T o 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission Term 3 year NAME Mary Therese Maher Sturm HOME ADDRESS 800 Eastmoor Drive, Iowa City, Iowa Is your home address (listed above) within the corporate limits of Iowa City? ~/ Yes How long have you been a resident of Iowa City? 50 years OCCUPATION Research Assistant rHONE NUMBER: HOME (319) 338-5161 ZIP 52246 a No EMPLOYER U of I ,Carver College of Medicine BUSINESS (319) 335-6633 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Long time Iowa City resident with a great interest in having a workable diverse community. While a Staff Council Member at the University of Iowa , I served on the Diversity Committee. On many occasions I have worked with University Employees trying to rectify employment issues that were exacerbated by the employees' ethnicity. __,_ 1 think I could be a good eye and ear for this commission. ' ; `; ~ ~: m~ z Anil-InT I~ vnl IR PRFRFNT KN(~WI EDGE OF THIS ADVISORY BOARD? --- Quite honestly, I have little knowledge of this advisory board but have been asked by several acquaintance to apply for a seat on this commission. I only know what I read in the newspaper ...and I have to say they don't get an enormous amoVht of coverage. 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR '~PPLYING-? Basic fairness in my makeup and a general empathy for those that are trying to "make it" in our city. 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. )ther 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 (see page 7-. If you 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. ~. -_ ~ _,.~ ...~ ~ ~.~ :. w . -~-~t - w, 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 a NO (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.l 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. Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Human Rights commission Name Mary Therese Maher Sturm 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. ~ r ~.._.®~~ ~m~ ~ -•~.a~_ CITY OF IOWA CITY Date f =~~ ~ BUSINESS NAME BUSINESS ADDRESS none ~~ .,' : ~' K-„ NOTE: -Anew form must be completed if the above information changes or an ownership interest is acquired in an additior}al business. ;=~i Signature Address 800 Eastmoor~ve, Iowa City, Iowa 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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income llow income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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. 65 Age female Gender 60%medianincome Income (see table) hetero Sexual Orientation Other (Please explain below) Christian/generic Religiv~ '~° _: ,., ,,, Y., .~I none ~l~lsabr~l"~ty j Race, color Caucasian or ethnic group USA National origin Human Rights Commission Application March 2008 Page 4 of 8 City of Iowa City ~ ~ -~..~ i~ Advisory Board/Commission/Committee .~' .`" ~~`~ -~ ~ `~. ~ ~lpl ~cat~on Form CITY OF IOWa CITY Individuals serving on Boards/Commissions/Committees play an impo~ant 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission Term 1/1/10-1/1/13 NAME Constance Elizabeth Goeb Cuttell HOME ADDRESS 145 Oakridge Avenue, Iowa City Zlp 52246..., Is your home address (listed above) within the corporate limits of Iowa City? ~/ Yes No -, ~_,,.1 How long have you been a resident of Iowa City? 8 months OCCUPATIONHuman Resources/Organizational Development Consulta Ph~NE NUMBER: HOME 310-938-0395 a ;y _ :....; 4._~.v ..a EMPLOYER independent consultant ~..1 s s --- .r BUSINESS 310-938-0395 __ EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: My background includes 30 years of experience in Human Resources, Employee Relations and Organizational Development in the public and private sectors and in small and large organizations. I have successfully negotiated labor contracts and settled grievances and arbitrations and have conducted investigations and resolved issues stemming from allegations of discrimination in race, gender, age, disability, national origin, sexual orientation and retalitation. Throughout my career, I have championed pro-active training and development initiatives such as "Conducting Effective Investigations", "Conflict Resolution", Diversity in the Workplace", "Mentoring", "Preventing Sexual Harrassment" and "Women in Leadership". I have a thorough knowledge of anti-discrimination laws and good employment practices and have worked diligently to educate management and the workforce in those areas. I am an Iowa native, have an undergraduate degree (Political Science) and a graduate degree (Public Affairs) from the University of Iowa. I returned to Iowa City in March 2009, after early retirement,and have been looking for opportunities to serve the community. Last spring and summer, I helped replant downtown, became a member of Project Green and have become a volunteer at the Englert Theater. I believe my professional background and personal interest in Human Rights would be a oood fit for the Human Rights WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? After reading the announcement, I went to the City website and read the Human Rights code. I made an appointment with Stephanie Bowers and spoke with her about the work of the commission, its role in the complaint process and in communication and outreach. We also spoke about time committments and expectations. I also attended the Human Rights Awards Breakfast to experience one of the significant outreach activities. 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYINGI? to~•~, City is a great place to live and work, and the environment has been built and groomed through the efforts of many cc nunity organizations including the Human Rights Commission. It can't be taken for granted. I am seeking an appointment to the Human Rights Commission because of my interest in continuing the advancement of Human Rights in our community. My educational background, knowledge, work experience and passion for education and outreach on human rights issues is well aligned with the mission of the Human Rights Commission. I am in a position to be able to commit the time and energy needed to be a commissioner for the next three years. Thank you for considering my application. 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. C ;r 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 (see page 7). If you 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. - _ .:3 F y-~ ~' ..,,,~ .` ' i_.. $ '.' ...: 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 flt has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Jlisrepresentations 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. Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Human Rights Commission Name Constance Elizabeth Goeb Cuttell i ~ i ~~r ~"~,~ '~~.~' CITY OF IOWA CITY Date October 27, 2009 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none . BUSINESS NAME BUSINESS ADDRESS none ;, '_,, ,. ~.. ~a ;,~. - ~. NOTE: Anew form must be completed if the above information changes or an ownership interest is acquired in an additional business. Signature (~ Address ~ 45 Oakridge Avenue, Iowa City 1lisrepresentations 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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income 1Poverty Level) 50% Median Income 60% Median Income 80% Median Income flow income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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, 1 1-8-94) OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. Age ~~ Religion ~~.~ ~a ~d<c~ Gender ~ Disability ~/d~ ~ Income (see table) Race, color ~~~~~ ~~ca~ or ethnic group ('/~uc ut i~v~- Sexual Orientation - National origin a _~~ Other (Please explain below) ~, x~ ~,:. ;,,~ Human Rights Commission Application March 2008 Page 4 of 8 Marian Karr prom: Connie cuttell [conniecuttell@gmail.com] ;nt: Tuesday, October 27, 2009 11:09 AM To: Council Subject: Application for Human Rights Commission To: Mayor Regina Bailey, Connie Champion, Amy Correia, Matt Hayek, Mike O'Donnell, Ross Wilburn, Michael Wright I have completed and submitted an application for appointment to the Iowa City Human Rights Commission and I am asking for your consideration for that appointment. The application suggested contact with city council members prior to the appointment date. I am writing you to let you know why I am applying and what I feel I can contribute. I will follow up with a phone call to each of you to answer any questions you may have. I have recently relocated back to Iowa City following a 30 year career in Human Resources and Organizational Development. I lived in Iowa City while earning my undergraduate and graduate degrees from the University in the 1970's. I also worked in the Iowa City area (Hawkeye Food Systems) for six years in the 1980's. I chose to buy a home and live in Iowa City after early retirement because I know the city as a vibrant and active community with great people and great opportunities for work, leisure and culture and community involvement. Since relocating, I have volunteered in beautifying the downtown with the Downtown Plant Project, volunteered for the Book Fair and have become a volunteer usher at the Englert Theatre. I am continuing to look for other opportunities to become involved and the Human Rights Commission would be a great fit. A great deal of my career has involved investigation and dispute resolution. I have a thorough knowledge and significant experience in discrimination laws. Over the years I developed a passion for informing, educating and training management, supervisors and employees in non-discriminatory practices and promoting diversity, readership training and coaching and mentoring. I would welcome an opportunity to cntribute my knowledge, time and interest to the cause of maintaining and promoting human rights in Iowa City. Thank you for your time and consideration. Constance Goeb Cuttell City of Iowa City ~ - ~~®~~ 4dvisory Board/CommissionlCommittee ~~"I°~,~'~ Application Form 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Human Rights Commission NAME Jill Schnoebelen HOME ADDRESS 2422 Lakeside Dr #10, Iowa City, IA Term Jan 2010, 3 yrs ZIP 52240 N°.. .... ...: .. ;s Is your home address (listed above) within the corporate limits of Iowa City? ~/ Yes How long have you been a resident of Iowa City? born/grew up here, returned April 09 OCCUPATION social work PHONE NUMBER HOME (563) 506-5494 EMPLOYER Lutheran Services-in lob, E BUSINESS "` z,A~ ~^ ,~ _ EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: '~' ~. I have a Masters in International Law and Human Rights from the UN-mandated University for Peace. I also have relevant international work and volunteer experience: I was apro-bono legal advisor for refugees in Cairo, Egypt from Jan-July 2003. I volunteered with a human rights non-profit in Malaysia, helping with their annual human rights report and at a conference on torture. I volunteered with Women in Law and Development in Africa (WiLDAF) in Ghana for several months in 2005. That year, I also worked for Orphanage Africa as Projects Coordinator. Next, I worked with the US refugee resettlement program all over West Africa, interviewing refugees, taking testimony and preparing their cases for possible resettlement. After getting my masters, my thesis was published on Refugee Council USA's website (about challenges to the right to asylum) and UN High Commissioner for Refugees (UNHCR) published a paper I wrote about the human rights of persons accused of witchcraft in Jan 2009. I worked for UNHCR on a short-term contract in Yemen, interviewing vulnerable Iraqi refugees for possible referral to the US for resettlement. I now work with Liberian refugees in Muscatine, Iowa, helping to promote self-sufficiency and integration. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I was honored by the Commission last week as the International Awardee at the annual Human Rights breakfast. I have looked over the website and previous agendas/minutes. va Misrepresentations on this application will constitute just cause for removal of an appointee. If you tail to answer all the questions, Council may not consider your application. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? Beyond my volunteer and work experiences and education, I am passionate and committed to the promotion and protection of human rights. I especially think that education is important and in my current capacity as Refugee Community Resource Supervisor, I am often addressing the public about what it means to be a refugee and the path that brought refugees to the Muscatine community, which increases awareness, understanding and compassion. I am comfortable as a public speaker and am also a skilled writer. I like to know what is going on in the community and connect people to other people or other resources. Networking is vital to getting information out and increasing the impact that we can make. Having spent most of the past seven years abroad, I would like to help make a positive contribution to the city in which I was born and raised. ~.. j - s ,,, d~ .~ ., '..~ POTENTIAL CONFLICTS OF INTEREST ~ ~ a Please identify any potential conflicts between membership on the advisory board and yojr personal interests, including financial interests and your duties to an employer. `o 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 *hat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Jther 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 (see page 7). If you 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. 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 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. Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Human Rights Commission Name Jill Schnoebelen ~~~.®g7 .~III~~~ ~~ CITY OF IOWA CITY Date 10/24/2009 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none . BUSINESS NAME BUSINESS ADDRESS NONE ;:: NOTE: Anew form must be completed if the above information changes or an ownershi~?~1~it~eres~ is acquired in an additional business. '-' ; ; ., Signature ~~~~~ _, :: Address 2422~/akeside Dr#10, Iowa City, IA 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. av Y: T,~ '.'; "'3 ~ C d Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of 1:~ie 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 -~commity. ;,.'. Therefore, appointments shall take into consideration men and women of various radial, ` "' religious, cultural, social and economic groups in the city." (Ord. 94-3647, 11-8-94) :.` ` ' `~ s~ - ,~ OPTIONAL: '' PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 29 Age Religion female Gender 40% Income (see table) Sexual Orientation Other (Please explain below) Disability Race, color or ethnic group National origin Human Rights Commission Application March 2008 Page 4 of 8 ~_ City ~of Iowa City r ~ _,. _ - ~..,.®- Advisory Board/Commission/Committee ~."`I°,~'~ ..pplication Form cl~ 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Iowa City Human Rights Commission NAME Dr. Howard Cowen HOME ADDRESS 2664 Triple Crown Lane #5 Iowa City Is your home address (listed above) within the corporate limits of Iowa City? /~ Yes How long have you been a resident of Iowa City? 21 years OCCUPATION Professor, College of Dentistry -Dentist rriONE NUMBER: HOME (319) 331-9090 Term 2010-2013 ZIP 52245 No EMPLOYER University of Iowa BUSINESS (319) 335-6961 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Within my profession I have been an advocate for oral health care for underserved populations in Johnson County for the past 30 years. I have been Director of the Geriatric and Special Needs Program for the past 30 years and have been funded by United Way of Johnson County, Johnson County DHS, Pilot Program, Trinity Episcopal Church, The Gannet Agency, and other social service agencies to provide dental care to residents of nursing homes, medically, physically and cognitively impaired adults, indigent, homeless, county jail inmates, and homebound/hospice, residents. I was among the founding members of the now Dick Parrot Free Dental Clinic, served on the board of the Free Medical Clinic and work closely with both of these organizations as well as the Shelter House to provide dental care to those in need. I have served on the University of Iowa Human Rights Charter Committee for the past 2 years and have recently helped in the establishment of the Healthy Kids School Based Health Care Program. I just received a grant to provide oral care to the underserved children in the ICCSD and have 2 more grants pending. I have given presentations at the U of I Human Rights Week and have served on the planning committee. I was also nominated by Rep. Leach as a delegate to the 2005 White House Conference on Aging. \A/FIAT IC VCl11R PRESENT KN(1W1 Ff)C;F (7F THIS AnVIS(~RY R(~ARf)~ Limited to discussions with other members of the community and media coverage -;-, ,,' 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ..Wink the Advisory Board should have representation from as many different sectors of our community as possible. I believe, through my experience, I can bring an enlightened approach to the inequities of access to health care in our community. Which, I believe is a right and not a privilege. I believe in equality in all facets of life and have long been a proponent of equal rights for all. Since graduating from dental school at the U of I and receiving a Masters in Public Health, I have spent my entire career caring and advocating for the elderly in nursing homes and other underserved populations. I have received the American Dental Association award for Excellence in Geriatric Oral Health and the University of Iowa Council on Disability Awareness Award. I am applying for this position because I feel I have the experience, the background, and most importantly, the desire to be a part of an effort in improve the Iowa City Community by eradicating "any" form of discrimination. 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 +~at apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. .per 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 (see page 7). If you 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. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? YES ~NO c:o v DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? ~ 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. Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City BOard/COmrT11SSIOn/Commlttee Iowa City Human Rights Commission Name Dr. Howard Cowen ~r ,~- ~III~ CITY OF IOWA CITY Date 10/23/2009 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings?• Please indicate if there are none . BUSINESS NAME BUSINESS ADDRESS None ~. _ , ~: ,~ `:.j .. ,. .. ~. °~1 __ ~ :., ~ . ,, <;~_ :~ ; . --,. ~~ NOTE: Anew form must be completed if is acquired in an add~ional~usin~: Signature ~/,1.~/ (// f Address 2664 Triple Crov~i Lane #5 lo}~ra City aboy~ information changes or an ownership interest 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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income IPoverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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. 59 Age Jewish Religion Male Gender none ~ Disability above median Income (see table) Race, color caucasion or ethnic group heterosexual Sexual Orientation Other (Please explain below) United States National origin Human Rights Commission Application ~ ~' March 2008 Page 4 of 8 "~ ~ 1 City of Iowa City r ' o Board/CommissionlCommittee ~.~"~~` '~ Advis ry ~~ '~ ,application Form 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory NAME HOME ADDRESS mmission/Committee Name '~`-'ti~~~v-n- ~ ~~~~ Term ~ (~ ~~ Is your home address (listed above) within the corporate limits of Iowa City? zIP SzZ~ Yes ~ No How long have you been a resident of Iowa City? _ J%~~ ~\ ~ j OCCUPATION ~~~.-C~ EMPLOYER ~;c-l (%~~ ` ~~ G''`' " 'HONE NUMBER: HOME~~ ` ~~~~~ BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: s---> ~' ~,~ (~ ~~I~~'~~ a~ G~ ~O ~~ef t ~ U~ ' ~COw~1 r ` ~ ~5 E'.. ~'''7C.vt G ~,,~v` CC `` __ ,. ~.. ~, ' ~~ ,~ .~ - - --~- WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Q ' 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ~~` ~~ .i' U ~,~, ~ ~ ~ .`tom ,~ ~~ -,~ ~~ ~-~ ~~~~~ `~~Y,~ C~-3 ~~ ~~~ nn e 1 ~ ~: ~ ~. s~t~a e CN ~~C ~ T""'"C ti fit: f` 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. lther 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 (see page 7-. If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of the l,oae OT IV Wd, EJICd SC l:VIlldGl UIC ..Ily Hllv~i~cy ~ vi~wv u~ ,, ,, ,, ,, ,, ,, ,,. -, .:. '~ ` ~ ~a Mv, s:_ q ' .. .....r ;~.ayY9'N r ~ hd~ ~_~ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? YES ~NO T DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 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. `~ ~(a/h. ~~j~'Y~~ ~~;,~. ev~~5 Human Rights Commission Application March 2008 Page 2 of 8 .:~.ri~:+®R~' ~II1~~~ BOARD, COMMISSION, & COMMITTEES -~-•_-- BUSINESS LISTING CITY OF IOWA CITY Name of City Board/Commission/Committee ~~^-~~ ~~ ~~ Date ~ U " Z ~ ~ ~~ Name ~~~ ~w~~°~ - ~- 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 (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS .~; .*, ..:~ -~ .~, ~11 l ~Y •*~ NOTE: Signature Anew form must be completed if the above information changes or an ownership interest is acquired in an add~l business. .. Address ~~ J ~' ~ ~'~'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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective March 19, 2009 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $15,950 $26,600 $31,920 $42,550 $53,200 2 18,250 30,400 36,480 48,650 60,800 3 20,500 34,200 41,040 54,700 68,400 4 22,800 38,000 45,600 60,800 76,000 5 24,600 41,050 49,260 65,650 82,100 6 26,450 44,100 52,920 70,550 88,200 7 28,250 47,100 56,520 75,400 94,200 g 30,100 50,150 60,180 80,250 100 300 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." IOrd. 94-3647, 1 1-8-94- npTlnnlnl PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. Z6 Age ` ~x~ ~' Religion ~ Gender ~ t ^'~.~~ ~ isability 1f ('3 ~ Income {see table) r V~~ Race, color or ethnic group ~~~~ Sexual Orientation ~~ C~ztc~4-v- Other (Please explain below) ,~~,. National origin -v, .ii ^- ~.. ~.i ~ J Human Rights Commission Application ~~= >> March 2008 Page 4 of 8-:-~ City of Iowa City ~~~~ Adviso Board/Commission/Committee ~,`'~.~;~'~ ry . ,pplication Form cIT~OF IOWA c1TY 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 BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/CommissioNCommittee Name Iowa City Human Rights Commission Terri 01/2010-12/2013 NAME Debra (Deb) A. Derksen HOME ADDRESS 3645 Rohret Road, Iowa City, IA Is your home address (listed above) within the corporate limits of Iowa City? ~/ Yes How long have you been a resident of Iowa City? over 15 years OCCUPATION Homemaker r , BONE NUMBER HOME (319) 400-0996 ZIP 52246 ~No EMPLOYER Self-employed BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I have worked with a wide vane#y of community and volunteer service organiza#ions, including Crop Walk, American Cancer Sudety, Jump Rope for Heart, for my children's schools, #or my church, and political party. 1 have also done volunteer work with Amenity Hospice in Cedar Rapids. I have a spedal affinity for those of our dfizens who are dealing with the stressful issues involved in end-o#-life care. In these roles I have taken leadership ~sitions, as well as worked as a general volunteer. As a result I have a very diverse background and experience wi#h many human rights situations. This is an important area of work for me. •~ .~-~ ,3 .. ~ ..' ~~: ~ ~a r~~, f . w. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARU? I have a general awareness of this advisory board and it's rote in promoting human and civil rights in Iowa City. tt~as been very effective in addressing these issues of discrimination and human rights over the past years. I am personally acquainted with a current member of the board, Yolanda Spears. Misrepresentations on this application will constitute just cause for removal of an appointee. I# you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? peel that as a woman, wife, and mother, dealing on a daily basis with the issues facing families and children today I can make special contribution. I have also worked outside the home, and know the struggles families face in balancing work and family a member of a very diverse religious community, the Mennonite Church, which works very hard to "help the underdog" and ~ has a special focus on peace issues I am aware of and interested in doing what I can to help those facing human rights 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. ier 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 (see page 7). If you 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. -, F:, None -- i ~,.~-~~ ~.,~ ` ~,V 3 n~ . , ._; ~ - ,;. __.. .. v 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 a 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. Human Rights Commission Application March 2008 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City BOard/COmmISSIOn/COmmlttee Iowa City Human Rights Commission Name Debra (Deb) A. Derksen 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 3fi2.5 is attached (see page 7). List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none . ~~~~o~ :.111, ~~'~ +. ~~l~ -.t.a~_ CITY OF IOWA CITY Date 10/28/2009 BUSINESS NAME BUSINESS ADDRESS None :,a --~ ~, ,~, '"~ ~ °`i -~aq ° ~ --g- ~2-~cJ' _., NOTE: Anew form must be completed if the above information changes or an ownership interest is'~acpun~ed in an addFtlYOn;~l.~usiness. ~ Signature Address~45 Rohret Road, Iowa ~; IA 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. Human Rights Commission Application March 2008 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty LeveO 50% Median Income 60% Median Income 80% Median Income flow income) Median Income 1 $15,250 $25,400 $30,480 $40,650 $50,800 2 17,450 29,000 34,800 46,500 58,000 3 19,600 32,650 39,180 52,300 65,300 4 21,800 36,300 43,560 58,100 72,600 5 23,550 39,200 47,040 62,750 78,400 6 25,300 42,100 50,520 67,400 84,200 7 27,050 45,000 54,000 72,050 90,000 8 28,800 47,900 57,480 76,700 95,800 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. There#ore, "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. 49 Age Mennonite Religion Female Gender None -~ Disability Medianl4 Income (see table) white Race, color or ethnic group Hetrosexual Sexual Orientation a Other (Please explain below) Native bom American 1 National origin - `:= ;:~ ~; ~y4y. rv ~~ L;g ,,,~~ _. Human Rights Commission Application March 2008 Page 4 of 8 City of Iowa City ~ r .:.:.®~ Advisor Board/Commission/Committee ~' ~~" ,~'`'~~ Y . ,ppl ication Form "'`-"- 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, in., .....:~a„ nl., ~~` 1r r~" ~ r ~ r r~ : ,. f, TPfnl \UVIJVIy UValwl+Vi u~nioaw~uvv„.....aa..... ......... Youth Advisory Commission (shall not be more than 18 years of age at the time of appli~tionj~W..-, ...,,{ 8 Name of Iowa City High School or high school equivalent: "".~ =- a-, .. Signature of parent/guardian: "~~~ 'AME HOME ADDRESS _ , - ; t , Is your home address (listed above) within the corporate limits of Iowa City? -aa ZIP Yes ~ No How long have you been a resident of Iowa City? ~~+~CS OCCUPATION !EMPLOYER PHONE NUMBER: HOME _~"~~D BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: l L/ ,jam ,~. U ~j~l ~ ~ DY~CC~ 7/IC' ~~SV D ~l L$' I t ~ J f' y /p v J ~ e,~'n-gyp _ S 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 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE RFA~C~N FnR APPLYING)? ~~ Ce-h vh ~ Vlt~s' i~~~ ~ !,,' ~ R 7'rq,~ ~' yon r ~ /~ a 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 far 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 knowthat 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. _ ~+ ~`~~`~ 3 --, IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~'es ~ No 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 may not consider your application. General Application December 2008 Page 2 of 7 _~ r ~~~~~ BOARD, COMMISSION AND COMMITTEES ~ `~~~~` "s BUSINESS LISTING -•ti.as._ CITY OF IOWA CITY Name ofi City _/ ~ ) Board/Commission/Committee l'~'~'rn~ / ~' ~ ~S rh oril Date ~d ~~ Name l C~61!'' /~~/~ 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 (see page 6}. NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional busingss. Applicant Signature Signature''o``f parent/guardian ou Addressyg ,~, /ivGci ~hA isory Commission only): 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 2008 Page 3 of 7 List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (far example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. City of Iowa Gity _ ~ ~~~~x Advisor BoardlCommissionlCommittee ~ ~`" ,~"`_~~ Y ~ pplication Form cI~ of IOt~'VA cITY individuals serving on Boards/Commissions/Committees play an impdant role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa Gity. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next forma! Councih~eeting. Appointees serve as unpaid volunteers. This form may be filled out manually (please use a black ink pert)typewritten, or electronically (PDF). Return the application toCity Clerk, 410 E. Washington St., Iowa Gity, Iowa. THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR TH 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 THA~ TIME. Advisory Board/Commission/Committee NameHuman Rights Commission Term 1/2010 to 12/2013 NAME Kelsey Miller HOME ADDRESS 100 Daum #5301 Iowa City, IA 52242 ZIP 52242 Is your home address (listed above) within tle corporate limits of Iowa City? QYes ~No How long have you been a resident of lovv~a City? 5 months OC C U PATI O Nstudent F..JNE NUMBER: HO1~1E(319) 353-0040 EMPLOYERUniversity of Iowa <; .~ . .~. ~~ BUSINESSnIa 3 _' e of ,: _.._, EXPERIENCE AND/OR ACTIVITIES WHICH YOUFEEL QUALIFY YOU FOR THIS POSITION e,-~ ~, M^ -"~ Last year, I served as a community youth board member on the Youth Area Philanthropists (YAPPERS]=board in~ny hometown. The YAPPERS board is a part of the the Community Foundation of Greater Dubuque. As a YAPPERS membet;'~ worked with other high school students to assess issues affecting local youth, such as equal opportunites in education. We developed ideas for achieving the goals outlined in the Every Chlid, Every Promise initiative and hosted an Empty Bawls fundraiser to prevent hunger among Dubuque youth, I am also dedicated to ensuring all citizens have access to affordable housing; which I have demonstrated this year through volunteering with the University of Iowa Habitat for Humanity Campus Chapter and the Iowa Valley Habitat for Humanity. Additionally, I am a volunteer at the University of Iowa Hospitals and Clinics. WHAT IS YOUR PRESENT KNOWLEDGEOF THIS ADVISORY BOARD? The mission of the Human Rights Commission is to prevent human rights violations, as defined in Title 2 of the City of Iowa City Human Rights Ordinance. The advisory board receives complaints filed by Iowa City citizens and provides training and educational materials aimed at educating citizens about discrimation, including discrimiation in the workplace and the housing market. The board also holds an annual Human Rights Awards Breakfast to honor individuals with outstanding work advancing human rights. 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. Human Rights Commission Application March 2008 Page 1 of 8 WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKETO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING}? I ~ a first year honors student at the University of Iowa aspiring to enter the medical field. I am interested in relations between c~ .~al groups and am currently pursing international studies and a major in Spanish. Serving on the Human Rights Commission will allow me to better understand issues affecting citizens' rights and will grant me the opportunity to help ensure that all Iowa City citizens maintain equal rights. i believe that serving on the Human Rights Commission will also broaden my understanding of diversity and discrimination and strengthen my abilities for a future of work in the medical field serving diverse populations of patients. 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 aarticular, 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 th~t apply far funding from the City. "Affiliation" includes being a board member or employee of the agency. G ar 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 (see page 7}. If you 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. n/a .. ~,~ ~~ _~_ -~~ •~ -r± ~' (~ '`, r.,.~,J IF YOU ARE NOT SELECTED, DO YOU WANTTO 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 serve on two Boards or Commissions at the same time.i 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. Human Rights Commission Application March 26CS Page 2 of 3 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Human Rights Commission Name Kelsey Miller 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 (see page 7}. List all businesses in which you or your spouse/domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings}. Please indicate if there are none. Signature 0 '~ 1 ~::lll~ ~ w~ as"~~ -•~~.a~ CITY OF 1CWf', CITY Date 1 ot2~io9 Address 1 QQ Daum A~c+rnr~rnc~nfiAtllll'1C ~n tnis annlication will constitute lust cause for removal of an appointee. 1 Iowa City, IA 52242 NOTE: Anew form must be completed if the above information changes or an ownership interest is acquired in an additional business. Human Rights Commission Application March 20Q8 Page 3 of €~ TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 13, 2008 Household Size 30% Median Income (Poverty Level) 50°h Median Income 60°~ Median Income 80% Median Income (low income! __ Median Income 800 ~ $15,250 $25,400 $30,480 $40,650 $50, 2 17 ,450 29, 000 34, 800 46, 500 58, 000 3 19,500 32,650 39,180 52,300 65,300 4 21, 800 36, 300 43, 560 58,100 72, 600 0 5 23,550 39,200 47,040 62,750 78,40 6 25,300 42,100 50,520 67,400 84,200 7 27, 050 45, 000 54, 000 72, 050 90, 000 g 28,800 47,900 57,480 76,700 95,800 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. Age )g Gender ~e mc~~ ~ Income (see table) Sexual Orientation Other (Please explain below} Religion Disability _., Race; color or efi~inic"group . ~-.~, .. _,~, .~ •- Nat~~al q~f`~in .. .~, .. _,. rM ~.~ Human Rights Commission Application March 2008 Page 4 of 8 22d NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: PARKS AND RECREATION COMMISSION Two Vacancies -Four-Year Terms January 1, 2010 -January 1, 2014 The duties of the members of the Parks and Recreation Commission are to recommend and review policies, rules, regulations, ordinances, and budgets relating to parks, playgrounds, recreation centers, and cultural functions of the City and make such reports to the City Council as the Commission deems in the public interest; to exercise broad responsibility for the development of parks, recreation centers, playgrounds, and cultural facilities to serve the City--including the creation and appointment of advisory groups to make studies. Iowa City-appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Parks and Recreation Commission meets the second Wednesday of each month at 5:00 p.m. Applications must be received by 5:00 p.m., Wednesday, October 28, 2009. 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 Parks and Recreation Commission should be directed to Mike Moran, Acting Parks & Recreation Director at 356-5110. PARKS AND RECOMMENDATION PARKS COMMISSION August 19, 2009 Page 8 of 8 ,~~~ AND CI"~Q! COMMISSION ATTENDANCE RECORD YEAR 2009 NAME a ~ o' TERM ~ 'rl ~ '"~ ~ 00 t M n ~ o ~ n rn ri ~ ~ a~ \ o ~ ~ N ~.., N M EXPIRE S David 1/1/11 X O/E X O/E X X X X Bourgeois Lorin Ditzler 1/1/13 X X X X X X X X Maggie Elliott 1/1/13 X X X X X X X X Craig 1/1/11 O/E X X X X X X X Gustaveson Aaron 1/1/13 O/E X X X X X O/E X Krohmer Margaret 1/1/12 X O/E X X O/E X O/E X Loomer Ryan O'Leary 1/1/10 X X O/E X X X X X Jerry Raaz 1/1/12 X X X X X X X X John 1/1/10 X X X X X X X X Westefeld KEY: X = Present O = Absent O/E = Absent/Excused NM = No meeting LQ = No meeting due to lack of quorum 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: 4 Females: 3 Council Announcement Date: September 15, 2009 Application Deadline: Wednesday, 5:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 PARKS AND RECREATION COMMISSION Two Vacancies -Four-Year Terms January 1, 2010 -January 1, 2014 Term expires for John Westefeld, Ryan O'Leary John Westefeld ~ 4831 Southchase Ct Clayton "Clay" Claussen 2145 Palmer Circle Dan Tallon ~ 320 S Gilbert St (Currently serving 2~d Four-Year Term) [~ ~ Denotes applicant completed the Confidential page of the application. ~ ~^' e^S f, ~ ~ i ~ ~ ~ ~ Ft '~ ~ ~} 53 F 3~ ~ ". { ~~ ~~1 ~ Lf ~ t,~1",~I ir~d#aidual;~ ~~~~#ng ~i"~ ~C~~rt~"~tf.1,E~i.F~;~.~ts.t,~~~~z.~.€"iii`ii~t~.`~,: (~Ic~ ~~# ~.Ft(,..?r~ ~i` °C~t In ca JI~.n(~' ~r"i„ ~f)L!_ ~. ~i~`s ni~tte; ~ cf #rltei`~s; t~ ou G~~'~r~;"is~rri*~` ~l#~ #~~ '__~"+~#rt~...Appl#%:~~i~ irti.9~t r~s#{~e in ,~•'1'ct City. After a vacancy has dean ar~nounce~d. t~~le Council reviews ail applications during the work session. ~ he appointment is made at the next formal C~rincil meeting. Appointees ser~ae as r#npaid volunteers. This fora may fie filled out manually (please rise a Mack ink pen), typewritten, or electronically (PDF}. Retr#rn the appli~~atic~n to City Clerk, ~r1~ E. ~"~asf~rin~i~:3rr St., Iowa City, 1o~1~~a, THt~ r~.~=~~=~.iC~~"iGi`~ ~°:} ~, PI~~L;~ i:;~.:1~::U~~~IE~~d~i AID A:~ ~UCi--i Cr~N BE REPRODU~~;EC~ AND DISTRiBUTEC) FOt~ THE PUBi_IC, 'J1ilTH THE EXCEP~f"iOf~l OF THE t_A.ST PAGE It1kARKED '`~UfV~I~-EidT'lAL." THIS APPLICATIGiJ 'JVILL BECON~IDERED FOR THREE ~~iONTH~ Of ~~_Y A!`•~D AUTOM~TfCALLY CONSIDERED FOR AN`Y VACANCY' DURING THAT TIIl~E ~f .~ ~ ~ %1 ~~n ~~ Advisory Boar fCommissian,`Comrnittee Name Z~tG Youth Advisory commission (shakl not be more than 18 years of age at the time of application} Name of Iowa City High School or high school equivalent: ________~~__~~~~_.- ~: -~, ..::.. Signature of parentlguardian: ~ ___ _. :~, R~ ~s;~}'3E. HC1iv~E ADDRESS (,~ r ~' PG1/1 / l1 ~' ~~- ~F f/lf~s_P''') Term _ ~-`'~ 1~ ~ ~ _ Is your hoi~ie address (listed a~~ove within t1rEe corporate lir~~its of lo~~~a City's Yes ...-~ ., -.- ..'1~. _a ~ ~..~ _ r~; _ No How long have yor€ been a resident of lorrva Cit~~'~ ~~ ~t ~ ~ 1 r~ t OCCUPATION . ~~~~ ~ f ~ ~/ ~~` Ef1l~P~_OYEi ~ ~- _ ~ ~~ PHONE NUIVIPER: HOME __~' ,~ ~ _ ~ ~ ~ ~ BUSINESS e 3~~ ~~~`~ ~ `~_ _ EXPERIENCE ANDiOR ACTItIITIES 1NHiCH YOU FEEL t`~UALIFY YOU FOR THIS POSITION: ~ ~ >~ ja~C~~ ~~~ P ~~ s_ ~~ ~~1~/ V ~ ~Zi`P ~ ~ = ~~ ~ ~s ~~~-~ ~~ ~ ~-~ ~~ ~~-,S, V~ f~ :~ _ 1; r"rr.a~ cVy z/ t' j /~~,~ _~~ ~ ~~ , . ~~. r ~ -- ~, y ~r. [['~yy'yy _. g r, k .E_ ~ jY'o§' ;~yy'~{''I tl ~, ~" ~~t"? ~ ~4r5P„ 4,-'(;t ~. jell i`~:k~r~~3@,~', i't.~Ii~`.~ 4Ai! ~i. ,.~ti ,~i~~ - - ..... . s f1E.. ... .~pp f .. ~~ s°~. }",:, ~~ ~ ~ ~ ~ ~( Gl~ L~u~ /I l /~ VVfl~t.l Ck_INTR{C~IJTIVNS V°....~ Y~1,.f ~EE~ €~_'~ €.~,`1",li~} ~~.?~C~,~ ~9~,.+ !I-41t4 6`1LJV~SVS~i ~~`V~RI.I tl,lf~ 'f,~,r.~~. REASON t=Ol~ ~o?PL`r'ENt.~~ _.....~.n.____-._.._._ ...~.~~._.~_.~.~...d.~_..,_._.-._~. _,~.,.~w~._,~_._..~.._ _~__ .~. __._._ '~,. ~ 1 `~ ~ ,~~ ~ :_ ~ ~~~ ~ ~ ~ i ~ ~;~ -~~~ __ :~ .., _ _ POTENTIAL CONFLICTS OF INTEREST - '~..' ~~ _ : _ -<~ Please identify any potential conflicts between membership on the advisary bard awl y~ peE~sai~al d~tts're st_s,irci~xdEng finartcta! ip~~r.~~eStc a~~ ~{~?~~' ~~.±t~~~ t4:~ c'~~ U~plr~~t~t C" :..+ ..s l~~ p~~ticular: if you are applyii ~g to t:e a member of a baar~d ar canR,missian wl'~i~.;{~. ~~ai*e~ recarwa~~~c~at~r : f~~~;~ Citm, auncil ,atZaut the allacatlan of Cit°y funds, please list ariy present affiliati~ans you ha°~e wit~~ ager~ ~~~9 ~-~' apply far funding fram the City. "Affiliation" includes being a beard member ar employee of the ager~ .. . types of affiliations must be examined an a case by case basis by the City Attorney's office. You shauld else knawthat Sectian 362.5 of the Cade of lava generally prahibits,with certain impartantexcep±ians. a member of a city Beard ar Cammissian fram having an interest in a city contract. A capy afSectron 362.5 is attached {see page 6}. If you are uncertain whether a patential canflict of interest exists ar have questions about Section 362.5 ai theCade of Iowa, please cantact the City Attarney's affice at 356-5030. IF YOt~ ARE: Nt7T SELECTE~s, L`O YO~.~ 1~tlANT T~O ESE PJOT11=1~~~~'? Yes Na ~O YOLL!.~ ~t;_~~~r;~ENTi_Y SfER,~ : ~N Af~~~,}~~l--tE~=, ~t'~~`."" ? ITY i~~` `.~"~ E:~R CGt,~ iISS,~?~;,x'° ~ ~ ,~~ ^~c ~~$. `~c; ~= 1.~~ ~.~~ s~t~il r =s 4."~' ~~ i r,'. ~~ C""jf. ~ ;"~~. f' .~ ..i~' - :"; ': E_rt:.. .. 1,~.... ;? 4' *. ...~ r; /~'i<'~ 4~. l~~~sr~~~o_" at~~:~r~~ ~=~k ~~~ b~ppl~~;~ag~€~!~ ~~~~3 =,< ~~s: ~~ ~us~ ' for rer?~~:~~~~~ ._m3 a~~ a~~~o3{~t~.~. '~ °~;~°r ~~~~~ C~n.~?~~~ ;.. i tl .~'~' ~..~4~I~t`o ~- , `al~~.,~~~~b~l r~~i~, y~ d!._l~ ~ :~!e~ y~ = g ~E~~L~t~~n, hlatne cf F~ity ~3oardl~at~nmissionfCommittee ~lat•~rte ~lT~l~, ~, ~ ~~ ~4T~' C)f ~~-~t`~';~, Ci,~;, mate ~ - ~~.~`~~~( Section 362.5 of the bode of Iowa generatty prcl~it~its, with certain im}~ortant exceptions, a merrtraef ; f a city hoard or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page ~~. fist all businesses in which you. your spc#~tserdc~mestic partner, or parent if Youth Advisory C;ort-tmission applicant:. have an ownership interest (fear example, sale proprietor, partner, 5°I~ or more of corporation's stockholdings. Pease indicate it there are none. NOTE. A new form must be completed if the above information changes or an ownership itaterestis acquired in art additional business. ! ~~ Applicant Signature. q ~~~~.~Vy~~~v Si^'gnature of rFarent~guar t~t (`~`eutl~ j/Adv scar ~~~mmi/`s/Nj/~.s~(i~o/ ~n~ly;:rN_,... ~~fy/_//~/~/_/_}~._._._ -.--__ _ _._~__._.~_____. ___..v._.. _~~_-~--~~ .._~~..•~^^ _~y21it V .~ .e.._®~a i~~ttsrep~ .. :;;°... 1+.2~t~~';6, ,3 - '.Y.xsvWlzs' ~....a.. s~ ,-~~''<<la;Ca~a{.'ts.# ~dvS.d. _ _.e... pi. r.~~.~ , ``'~ ...~...m.. .... -. ~ _, ~g`1t ~~..$~i~~.?`l._ ~ ..- ....~~..... -....~ ....Y ° ~lJ~# J~3~t~S. 'J~,?,.. ~L~ti _`~ ~ns~~~er :iii th~? ~i, a,~a_~ ~~c~rtt~~~ t~ 'tay , t,.:;. Es t.~tdet ~~ ':~.~~{ltcattor?. li i~~x rya r~Y ~-' , E_ City of Iowa City _ r, r 1 ~~`~. ® ~ Advisory Board/Commission/Committee ~,,~'~~ 'application Form -"~-~-- 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 Parks and Recreation Commission Term 1/1/10-1/1/14 Youth Advisory Commission (shall not be more than 18 years of age at the time-,of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: ~' 3 NAME Clayton M. "Clay" Clausen - - -. . ~10ME ADDRESS 2145 Palmer Circle, Iowa City, IA z}p 5224 r 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? Currently, 7 years, previously, 20 years OCCUPATION Realtor EMPLOYER RE/MAx Affiliates PHONE NUMBER: HOME 319-351-4295 BUSINESS 319-331-9911 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Fitness/wellness/health promotion manager and consultant (20+ years): As founding Director of Rockwell Employees Recreation Center in Cedar Rapids, I helped create and successfully operate one of the largest on-site corporate recreation centers in the USA. Accredited as Health Promotion Director by Dr. Kenneth Cooper's Aerobics Institute, Dallas, TX. Founding member of Austin, Texas, Well City Initiative. Assisted in successful launchings of two local private fitness centers, Core Fitness and Performance Health 8~ Fitness. Served as a Board Member for Iowa City Girls' Softball. Served as member of Regina School Board. As a Realtor, I have a vested interest in developing programs and facilities to serve all our citizens and enhance our community. As a resident of the Southeast side of Iowa City, I want to help solve our social problems. 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 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I understand the Commission serves in an advisory capacity but can recommend and review policies, rules, regulations, ordinances and budgets relating to parks, playgrounds, recreational centers and cultural functions of the ^ity WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? understand how important recreation can and should be in the lives of our fellow citizens. I have a unique set of 'skills as a result of my extensive management and consulting experiences and would love to contribute to my community. I am aproblem-solver and a team player who has been able to work with diverse groups and interests to achieve excellent outcomes. I would like to help Iowa City remain on the leading edge. I have a flexible schedule that allows me to dedicate my time and energy to perform the work required of a productive commission member. 'As a Realtor, I know what an important role the Parks and Recreation Commission can play in shaping and enhancing the character and quality of life of our community. My sister-in-law, Therese Glowacki, is Director of Parks and Recreation in Boulder, Colorado, and she has provided me with insight into the workings and demands of her organization. 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 ity 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 knowthatSection 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. . `~ ~ N, ~,, -_- ___ . -_,, ~~ ~• ., f IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~ Yes ~fiVo '~~ DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? ~ 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 2008 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Parks and Recreation Commission ~~*t~.--..®~ ''~'®'~~ -~a.as__ CITY OF IOWA CITY Dat~O/22/2009 Name Clayton M. "Clay" Claussen 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 (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS CCG Properties (rental property) 1705-1709 H Street, Iowa City, IA 52240 Claussen Generations Group (RE/MAX AfFliates) 2751 Oakdale Blvd, Suite 3, Coralville, IA 52241_ NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature, Signature of parent/guardian (Youth Advisory Commission only): Address 2145 Palmer Circle Iowa City, IA 52240 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 2008 Page 3 of 7 City of Iowa City ~,!, r _ j ~.,.,...~~r Advisory BoardlCommission/Committee ~~~"';~'~~ Application Form -~-~-- C1TY 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 ~~C~3 c~;~J~ '4-~~- Term Youth Advisory Commission (shall not be more than 18 years of age at the time o1=-applicaton) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: ~ ~ ~ ~{-~ -_ ~~ ~-~ ,-j :. DAME ~~u~ ~ \c\\±~t ~~- T. ,. ~, ~ ~ ~ . HOME ADDRESS -~L~-' ~~ ~, ,~`~.~~-~~s <~~~z~s ZIP' SZZ~ 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 OCCUPATION ~~~J~C PLOYER `~~~c~b~~~ ~~~"~~ __ PHONE NUMBER: HOME ~G~ Z~~ ~~~ BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: vim' ~-k ~~(.~ /l-tc' ~~b .~ ~r~'~}2G G~ ~ti, °5 S~ ~e( , '-' ~'~-~~~1 ~~ ~ ~`' ` ~ ~ ~- r e' ~ S ~ ~GC~~S Gt,~ J 1 c tee S c, ~Cj.~~,~ ~, ~ ~ ~~^ ~~~ ~ `M. -~~ ,,, ~ y . F ,a ~~ ~1-z c ~~ C~'~ VIaJ -~, ,~ b L ~ e + ~ ~' I~ ~,,, ~ ~ ~~ cG~ 5 ~~tU~~QC`~ ~o ~~~ '`ULC 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 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? ~~ ~~ WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ~ ~ Q~ ~~ ~~;- ~~~~ ~~ ~~E~~: 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. .n 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 far 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section.362.5 of theCade of lowa,.please contact the City Attorney's office at 356-5030. .~.. e -, . ~ n~ ..~~ ,, w~ . - =~ ~,, r w 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 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 2008 Page 2 of 7 _~ r 1 ~~~~~ BOARD, COMMISSION AND COMMITTEES ~ .~~~~ ,~ '~ BUSINESS LISTING -•~s,_ CITY OF IOWA CITY Name of City Board/Commission/Committee ~~,~~-5 k~"~~ ~~-~- _ Date %G' Z~ C~1 6--- ~--~ Name ~ ~. ~. 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 (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS <_ ,..: .~ x „~ - _ . _ _: ~~ r4.~ "~ w NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. \ y Applicant Signature ~T~ Signature of parent/guardian Youth Advisory Commission only): Address ~ C ~' ~ y \~~~ C ~- ~~~ ~ ~-~ 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 2008 Page 3 of 7 Page 1 of 1 22~- Marian Karr From: ClayClaussen@aol.com Sent: Monday, November 02, 2009 12:40 PM To: Council Subject: Parks and Recreation Commission Applicant -Clay Claussen Attachments: Parks and Recreation Commission App Oct 2009.pdf Dear Council Members, I would sincerely appreciate your consideration to serve on the Parks and Recreations Commission. I am attaching a copy of my application which details my extensive professional background in fitness, wellness and health promotion as a manager and consultant. I would love to be involved in helping us maintain and enhance our image as a leading-edge community in terms of providing recreation opportunities and services for our fellow citizens. I have worked successfully with a wide variety of corporate, public and private entities* and want to be certain we use all available resources in our mission. Please feel free to contact me directly by phone/text (319-331-9911) or email (clayclaussenCa~aol.com) to discuss any questions or concerns you may have. "Rockwell-Collins, John Deere, Quaker Oats, Ertl Toy Company, Dell Jewish Community Center, Trilogy Software. At your service, Clay Clay Claussen 2145 Palmer Circle Iowa City, IA 52240-5901 Cell: (319) 331-9911 Home office: (319) 351-HAWK(4295) Email: clayclaussenCc~aol.com 11 /2/2009 11-02-09 22e NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMITTEE: PUBLIC ART ADVISORY COMMITTEE One Vacancy -Three-year Term January 1, 2010 -January 1, 2013 One (1) Art/Design Professional 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, October 28, 2009. 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 Marcia Klingaman, Neighborhood Services Planner at 356-5237. 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: September 15, 2009 Application Deadline: Wednesday, 5:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 PUBLIC ART ADVISORY COMMITTEE One Vacancy -Three Year Term One (1) Art or Design Professional January 1, 2010 -January 1, 2013 Term expires for Mark Seabold No applications as of Wednesday, 5:OOp.m., October 28, 2009 DDenotes applicant completed the Confidential page of the application. 22f NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: SENIOR CENTER COMMISSION Three Vacancies -Three-Year Terms January 1, 2010 -December 31, 2012 The duties of members of the Senior Center Commission are to: Serve in an advisory role to the City Council with regard to needs of the Senior Center. Make recommendations with regard to policies and programs at the Senior Center. Join staff and other interested persons in seeking adequate financial resources for operation of the Senior Center. Encourage full participation by senior citizens in the programs of the Senior Center. Ensure that the Senior Center is effectively integrated into the community and cooperates with organizations with common goals in meeting the needs of senior citizens. Serves in an advocacy role with regard to the needs of senior citizens in Iowa City. Iowa City-appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Senior Center Commission meets the third Tuesday of each month at 3:00 p.m. Applications must be received by 5:00 p.m., Wednesday, October 28, 2009. 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 Senior Center Commission should be directed to Linda Kopping, Senior Center Coordinator at 356-5225. Senior Center Commission Attendance Record Year 2009 Name Term Expires 1/20 2/17 3/24 4/21 4/28 5/19 6130 8/25 9/15 1012( Mercedes Bem-Klug 12/31/11 -- - X X X X O/E OJE Chuck Felling 12!31/09 NM NM X X X X X X Jay Honohan 12/31/10 NM NM X X X X X X Michael Lensing 12/31/10 NM NM X X X O/E X O/E Sarah Maiers 12/31/09 NM NM X X X X X X Charlotte Walker 12/31/11 -- -- -- X X X X X Nancy Wombacher 12/31/09 NM NM O/E O/E O/E X X X Key: X = Present O = Absent O/E = Absent/Excused NM = No meeting - = Not a member 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: 3 Council Announcement Date: September 15, 2009 Application Deadline: Wednesday, 5:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 SENIOR CENTER COMMISSION Two vacancies -Three Year Terms January 1, 2010 -December 31, 2012 Term expires for Charles Felling, Nancy Wombacher Janice Frey ^D 922 N Dodge St Charles Felling ~ (Currently serving 1St 3-yr term) 825 South 7th Ave Brian Sabel ^O 430 South 7th Ave Jean Martin D 2254 S Riverside Dr #50 Richard Twohy D 319 E Washington St ~ Denotes applicant completed the Confidential page of the application. Gity of Iowa Gity ~ r 1 ~~~~ Advisory BoardlGommissionlGommittee ~~~:i-+~,~~,~ ~ lication Form pip CITY OF 104NA 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 wank 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 "CCiNFlQENTIAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/CommissionlCommittee Name Senior Center Commission Term January,2010- Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: _ NAME Janice Frey "' ;r .d ~-IOME ADDRESS 922 N. Dodge St. ZIR~52245 ~- '~? ~_• Is your home address (listed above) within the corporate limits of Iowa City? ~f Yes a~ N~ .~- cr How long have you been a resident of Iowa Gity? since 1988 OCCUPATION social worker PHONE NUMBER: HOME 319-351-1003 EMPLOYER unemployed volunteer senior advocate BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Since 2003 I have been involved with groups in service to seniors and persons in long-term care: for example. Iowa City Hospice, Johnson County Task Force on Aging, Resident Advocacy Program of the state`s long-term care Ombudsman's Office. I have a master degree in social work with a focus on Aging Studies and End-of fife Care. i am a member of the senior center and take classes there, as well as use the fitness equipment. I have developed a goad rapport with center staff and people using the facility. I am a baby boomer and have an interest in helping the senior center adapt to addressing the needs and interests of the upcoming seniors, while maintaining activities and serving those current seniors who participate in the various social and nutritional offerings available at the Center. 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. veneral Application December 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? The commission meets on the third Thursday of each month and serves in an advisory capacity to the City Council and City Manager. know several current board members: Charlotte Walker,Professor Mercedes Bern-Klug. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING}? My background in Aging studies has given mean appreciation for the aging process as one that involves all living beings. We age on a continuum. The Senior Center has an important role to play in helping members of our community successfully navigate the transitions we all experience over time. As a member of the boomer generation, it believe i can offer an increasingly relevant perspective. I feel that advisory committees must reflect our diverse community in order to remain viable and provide city officials with relevant and useful information on which to make budgetary decisions. t see the Center as providing the community a venue for social interactions across generations and diversities, which can improve understanding and promote cooperation and mutual respect. This attitude and my willingness to work with others for the good of the community make me an excellent candidate for this commission. POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory board and your personal irtterests,including financial interests and your duties to an employer. ~n particular, if you are applying to be a member of a board or commission which makes recommendations tothe ,ity Council about the allocation of City funds, please list any present off Nations 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 knowthat Section 362.5 of the 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions abciut Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. 1 am currently the chair of the Johnson County Task Force of the Heritage Area Agency on Aging:.., ~ ~_~ -•- ~.~~ ~; , .~,. ... IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~ Yes ~ fro `~. DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? ~ Yes ^f 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 2008 Page 2 of 7 BQARD, COMM[SSION AND COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committe~enior Center Commission ~.~:+~III~,~~ M~®~~~~ -~e.as._ CITY OF IObNA CITY Date Nam~anice Frey Section 362.5 of the Cade of Iowa generally prohibits, with certain important exceptions, a member of a city Board ar Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sale proprietor, partner, 5°~ or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS i.I Dnc (; .; . .. ._.; a - r~ .. .,,_~ ~.' NCfTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. AppNcant Signature, Signature of parent! only): Address 922 N Dodge St 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 2008 Page 3 of 7 City of Iowa City i r j Advisory BoardlCommissionlCommittee ~` ~~"';~'~~ Application Farm -~-~-- 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 RECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name ~C Y> ~ y ~' ~~ ~~ ~ -~ ~~~~ ~"z' y ~ °~rm Youth Advisory Commission (shall not be more than 18 years of age at the time of application) ~ . Name of Iowa City High School or high school equivalent: __» ~, ; Signature of parent/guardian: NAME ~e S ecc;n p (~ ~ HOME ADDRESS a ~ ~ _J _D ct_ t ~. ~ ~Gl~l ~t z° ~_ -~_ ZIP c~ ~0 Is your home address (listed above) within the corporate limits of Iowa City? ®Yes ~ No How long have you been,al resident of Iowa City? ~^ ~ t/~°Cc v~s OCCUPATION ~ ~ t' i r~ ~ EMPLOYER PHONE NUMBER: HOME 3/ Q 3 3 g w ~~ ~ BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: L W%!1 Ca~~~efe 3 1~a~5 ~i~c ~~~ S'iPn:ov~~H~~f- ~0~~~ s,r is K .~~ ~'~~ ~ ~5' i ~K/i~ ~--~~ a ~ a/U ~o. S','~e ~ ~aao ~Q1/`L° nRr!"i CiV7~~.d ~~~+z_/t~L~l~! ~+Cf~ ~LCCSSC°$ ~Q~Q S Q. V U L ~ ~ ~ e ~- `F' Z~ r L' ~~' lit G' 7'.' vi ~ - ~°. S . %~Y` : ~J N 3'~ v J o - .~ ~ ~-r5 `~' ~ ~e. S ~ r ~.- ~ ~ ~,. ~!> sz iY i S S ~ 6~.. .L- S ~r v e ~ rh.. ~ ~ L c~c~, w 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 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? /~ ) n /1 ~ 4 l' ~ /'YL iM c 5 5 ~. c~ l U Ct ~~ 3 CC.~ ~ ~ ~ ~ h O ~ ~ Gc~ -~ CJ ~'1' t ;,~, `tt~, u -~--~ ...~~,, ~ ; `~' ~ Cdr. ~+ ~ (d ~v ~ V Q„~~ -z~G~..Y ~ !~ S WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? t~ ~ ~ ~ ;~ 4„ 5 'f " U. ~.,,~ G .~ ~~ ..zr~/ ~e- r~/ ~ .~' G? i~ '~-'~- Lam. ~~ ~ ~ LS 5 l k'/H., 1 ~ lAi- /~~°. l'~ ~ ~ ~f[... r 1 - L ~ V ~ Lf i f~7/~ ' c-[. r~ '"~''V j !~L S .' f/ .....,R POTENTIAL CONFLICTS OF INTEREST w,. . -, Please identify any potential conflicts between membership on the. advisory board and.`~our 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 knowthatSection 362.5 ofthe Cade 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? p 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 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 2008 Page 2 of 7 _~ r ~'~~~`~ BOARD, COMMISSION AND COMMITTEES ,,W,~~,~~'`~ QUSINESS LISTING -•~,~,_ CITY OF IOWA CITY Name of City ~ / Board/CommissionlCommittee `e ~ r G t` ~`~~'~ ~D!'j'IiY~%Ss/ate l~~~r~,~G /S~; Name i ill,. 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 (see page 6). List all-businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (far example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS - _-;~ _ . -.:a NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. ., // Applicant Signature Signature of parent/guardian (You Address ~ ~ ~ ~ Urit~ Advisor~,Commission o~i): "Z~ ~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. V( General Application December 2008 Page 3 of 7 Page 1 of 1 Marian Karr From: Margaret/Chuck Felling [mcfelling@mchsi.com] Sent: Friday, October 16, 2009 5:45 PM To: Council Subject: Senior Center Commission application Chuck Felling Dear Council Members I have submitted an application to continue my service to the city as a member of the Senior Center Commission. Please contact me should you have questions. Chuck Felling 319 338 6994 10/ 19/2009 ~ 1 City of Iowa City ~ ~~®~r Adviso BoardlCommission/Committee ~' ~"'~'~~ ~ ~ ~~~~~ Application Form "'`-"- 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 Senior Center Commission Term 2010-1012 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: ~ ' NP"~E Brian J. Sabel HOME ADDRESS 430 South 7th Avenue, Iowa City, IA Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 8 years OCCUPATION Attorney EMPLOYER Self-employed (Sabel Law Office) PHONE NUMBER: HOME (319) 321-5844 BUSINESS (319) 338-5631 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Having been raised by my grandparents, I witnessed the challenges of aging with limited resources first-hand. This experience provided me with an awareness of challenges facing aging and elderly Iowans that many people my age do not possess. When I worked in banking, most of my clients were over the age of 65 and I gained valuable experience in working with the aging and elderly and developed insights on their unique needs. In law school, I took several classes which focus on the legal needs of the aging and elderly including Elder Law Seminar, Programs & Services for Aging Adults, Trusts & Estates, and Income Taxation of Estates and Trusts. Finally, although my legal practice is general due to the short amount of time I have practiced, I plan to build my practice so that I primarily work in Elder Law; Social Security Law; and Wills, Trusts, Estate Planning & Probate Law. "Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail ,~ answer all the questions, Council may not consider your application. General Application December 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I understand that this board works closely with the staff of the Senior Center, Senior Center members, the City, the County, and community members to provide programs and services to the elderly in Johnson County. I have toured the Senior Center on multiple occasions and am generally familiar with their programming. I also clerked for Mr. He han while in law school. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE R~ncnrv FnR APPI YINGI? I am deeply interested in the challenges that face aging Iowans and the means by which federal, state, county, and city governments; non-profit organizations; and citizens in general will meet those challenges. I have much to learn, as these issues can be complicated. However, I am ready, willing, and able to roll up my sleeves and take on the challenges to the best of my abilities. My education and experience have given me knowledge that I can use for the benefit of the Senior Center and its stakeholders. My personal interest in elder issues will drive me to gain knowledge where I lack it. I also realize that in order to accomplish these goals, sometimes work just needs to be done. I am willing to step up and take on the less glamorous tasks that, while not as fun or interesting, are nonetheless vital to the effectiveness of the Committee, the success of the Senior Center, and the improvement of the lives of aging Iowans. I will be one of the members to whom the Committee can turn when they need something done correctly. 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 ocular, 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 knowthat Section 362.5 of the 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section _362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. ._ ..~ None that I am aware. ~ y - _ ~~a ,~.~ ~... IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ^/ Yes U 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 serve on two Boards or Commissions at the same time.) ^~lisrepresentations on this application will constitute just cause for removal of an appointee. If you fail .~ answer all the questions, Council may not consider your application. General Application December 2008 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Senior Center Commission Name Brian J. Sabel 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 (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth AdvisoN Commission a licant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS Sabel Law Office (sole proprietor) P.O. Box 2716, Iowa City, IA 52244-2716 _...: ,_3 --•~ "1 'J i NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature Signature of parent/guardian (Youth Advisory Commission only): Address 430 South 7th Avenue, Iowa City, IA "Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail .~ answer all the questions, Council may not consider your application. ._, ~ ~ _ ,i w1` -+e.as._ CITY OF IOWA CITY Dat~O/22/2009 General Application December 2008 Page 3 of 7 City of Iowa City ~ r 1 ~_.;.®~ Advisory BoardlCommission/Committee ~',~~"',~'~~ _ application Form -~-~- 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 RECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name ~,ti~'0/C~, l.~l~i~L-!~l)iyl /h.LSrS~71~ Term .3 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: 4ME ~~ ~~~~ HOME ADDRESS ZZ ~- ~'~~ ~~- ~~~ ZIP ZZS~ 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? ~~HyS OCCUPATION _~ l~ __ ____ __ EMPLOYER PHONE NUMBER: HOME -~I~i~~(~~ jr BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ~-~ ~uA~ la/hyhi l j r~ l %C J~JA=; jON ~^~G~J{~ ~ ~ ~ ~ J~~ S ; _: :~~ _~ :, ,, ~., - ; _::, 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 2008 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? ~~ L%~l)i,if~~G~N ~~i '~G !,l ~1~~ ~4~L~ ~'~ I~CC ~ ~~lll~,f"L~c~~ " ~,~,~1 /~ C/nl/~7L~ !J '-~Fz~f~b~~~ ~~~~ ~-~i~~~'~~ e~' ~, : , r~s ~1,~;~.~ u .mac, c~~ : ''' a~I;IC(L ~ ~~ ~.~1'~C~f ., /z N r'N' >~~ ~~~ f llll~~C~-~'..flf?~~i~ ~/~' ~'~'"l7t-n't~ ~,` r i~ WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? 1 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 362.5 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. __t a ':.v ~~, .~t 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 0 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 2008 Page 2 of 7 ~ r 1 ~_...®~r,,~ BOARD, COMMISSION AND COMMITTEES ~ ~~~~~` ~ BUSINESS LISTING -•~a.as~ CITY OF IOWA CITY Name of City (~ ~ _, Board/Commission/Committee dC=/t.~rt~~- ~~'1~~- ~'~~ ~~'~d~ Date ~ Q - ~ ~~ ' ~ `l Name -._l~ !"t~t1~ N 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 (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS ., ~.~ v~ .~ y ~ _, ~ .- 6 NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional busin s. ~~ ~r Applicant Signature- Signature of parent/gu Address (Youth Advisory Commission only): 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 2008 Page 3 of 7 City of Iowa City ~ r 1 Advisory BoardlCommission/Committee ~:~-~",~'~~ application Form ~-'~-- 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 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: `:`{ AME HOME ADDRESS -~~ ~- ~ -.., ~a Is your home address (listed above) within the corporate limits of Iowa City? Yes^"~' ~lo How long have you be~~e~~n a resident of Iowa City? ~S OCCUPATION f~TJY EMPLOYER S'~~T PHONE NUMBER: HOME 3~9 60?~-`"~~ BUSINESS ~~ EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ~``-- Y .SJh~ C ~c Q~ .~ h~vc~ l n -~a '7L~~S hci ~~jothrb~ /' /~G~c_ ~G~cs~Y~1~1" l~~~N ~ cS~f`-~/~ . Sts ,t-~Grr~~ „L `~~ 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. ~1.°N/p-/~ ~Qh Qr (~h^~/h/.~SI~ N Term ~~ ~~ s~ General Application December 2gG8 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? /`jc~rC. a ~ 7b ~ca rh . WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? Le~s~~ ~ ~ ~'~ ~ vale, on esra~eS. c~~. J ~1 Sri ,~-s~ v~ ~~. , / r! >> y ~s `ice ~ ~~ tn/o'~h ~'ear~ ~/tL Cz ~~ , ~ .~ri~ ~ iP y J ~ ~ Y ~ -~ar ~~VVV/// Por~~~~e.S GCiS ~i~ l ~~ ~ec~si~,~J -s~i~ r'~n . ~ J y 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 far 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 knowthat 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. ~ ; _.~, ~`'v _ _,. _ _ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes f~a ~ '~~' DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION?* ~ Y~ 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 2008 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City - Board/Commission/Committee ~eA~~Or L~~ cr CD/yih~lsr/~~ Name ~~~~ ~~~®dx ~III~~~ 1. ,. .qM,®i~~ CITY OF IOWA CITI' Date y0 ~i O 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 (see page 6}. List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (far example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS d l0 ~ ~~ . .. _, ~ r ^+,.~ 7 NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. , Applicant Signature, Signature of parent/guardian (Youth ~~lvisgry Fj6mmission only): Address 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 2008 Page 3 of 7 22 NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: YOUTH ADVISORY COMMISSION Two Vacancies -Two-Year Terms January 1, 2010 -December 31, 2011 One (1) person -Regina High One (1) person - At-Large The mission of the Youth Advisory Commission is to promote understanding and awareness of Iowa City among Iowa City youth, allow a select group of youth to help make decisions concerning them and their peers, enable youth members to utilize and expand on their leadership abilities, to serve as a mechanism for communication between youth and adults in Iowa City and create a bridge whereon youth and adults can develop partnerships. Membership shall consist of seven [7] members appointed by the City Council currently enrolled in an Iowa City high school or high school equivalent. Four members shall represent City, Regina, Tate, and West high schools. The three remaining members shall be at large. All ages shall be calculated on the date of the filing of applications, and shall not be more than 18 years of age at the time of application. All members shall be residents of Iowa City. Applications must be received by 5:00 p.m., Wednesday, October 28, 2009. 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.orq. Questions about the Iowa City Youth Advisory Commission should be directed to Marian Karr, City Clerk at 356-5041. z 0 O X ii ~ m „ u a O O D D rt N N N c~ ~ ~D ~ ''~ '~ m = m 3~x ~ `~ c ~ O N cD A~ c 0 3 ~ N ~ ~ N~ ~ ~ ~ v == ,. v ~ ~ ~.' ~ n ~- ~ -~ ~. ~ ~ ~ v ~ ~ ~ -~ z ~ rn N W ~ 0 co N W ~ 0 co N W ~ ~ 0 N W ~ ~ 0 N W ~ ~ o N W ~ 0 co N W ~ 0 co N W ~ 0 co ~ ~ ~j z ~ z z z z m x x x x ; z ~ z ~ z ~ z ~ V Z Z Z Z Z N ; ; ; X X X X X G' X x x m x x X X X X X X w x x x m x m w ; X ; X X m X X °~ cr+ x X X X X m y X ~ X X m ~ X N ; x x m x ° x y X ~ X X X ~ X rN x x x m x x m x x x O C "'~ ~ D m v 3 m v ~ rt ~ z O v o m ~ ~, o~~ ~ ~ m O ,., O ~ ~ ~ v N O Z ; ~~OX u u m u n zzy~ rt ~ a N N ~ ~ cND ~ ~ ~~7 ~,~ cD ~ ~• m 3 x cau ~ c 'o~' ~D A ~- 0 ~ ~ ~ rZ~6 .~ ~ G7 ~ ~ ~ ~ ~•- ~' ~ ~' ~ _ ~ .-~- ~ `, ~ ~ 2 ~ ~ ~ ~' -~ C~ ~ ~ v ~ v ~ ~ ~ ~ z ~ m m N w ~ N w ~ N w ~ N w ~ N w ~ N w ~ N <~ ~ N w ~ X ~ ~ O O ~~ ~ ~ O O O CO CO O O O CO CO cD x x x ° ° x o X x x ~ ; ~ ; x N y j x x x 1 1 x ° x ; x x x o0 0 c ~ 2 ~D mo 3 rn o< D z0 v o m~ v o ~n ~ ~ m0 v O~ v~ 0 z -~ o -c ~~o ~, ~ ~ ,_ ~ co D ~ N ~ O < ~ ~ 0 ;L7 0 ~_ O z 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: 1 Council Announcement Date: September 15, 2009 Application Deadline: Wednesday, 5:OOp.m., October 28, 2009 Council Appointment Date: November 2, 2009 (Recommendations to be made by Council liaison) YOUTH ADVISORY COMMISSION Two Vacancies -Two-Year Terms One (1) person -Regina High One (1) person - At-Large January 1, 2010 -December 31, 2011 Term expires for Hannah Green, Jerry Gao At Large Arianna Aron D 700 South 1St Ave Alexandra Tamerius ^x 2911 Eastwood Dr Regina High No applications as of Wednesday, 5:OOp.m., October 28, 2009 ~ Denotes applicant completed the Confidential page of the application. City of Iowa City _ ~ ? l Advisor BoardlCommission/Committee ~'~~~""'~~ Y ',~~,~~ Application Form -~-~-- 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. f~+ - L-~'rc~C~ I, 1 l10 Advisory Board/Commission/Committee Name ~ r, c c -f-6t ~ ~ i Sc'~ ~2 ~t Term ~ ~ Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or school equivalent: C ~ 'I'~-t 1-~i r~~ Signature of parent/guardian: ~ 1~S ~(` (~ ~ ~ ~z~ NAME ~'I(;1,1111t~ ~~n `'~ HOME ADDRESS s~ ~_ zIP ~~ try ' Yes ~ No Is your home address (listed above) within the corporate limits of Iowa How long have you been a resident of Iowa City? OCCUPATION (~ ~ ~~ ~ r! I ~ l ~ 5~~1~1 ~ EMPLOYER ~ CC~`~ f1 C~ C~Ci- PHONE NUMBER: HOME C~~I~ ~~~ 1 ~~y BUST-NESS ~~.`tCll~ S~CGre- EXPERIENCE ANDlORACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: S1~'~Glt(1~. ~nGt,~.l1C' l ~ (~C C~~S ~9 ~-~t-~ ~1` \`~t ~. -l I`° CX 11`1 c~ ~. Misrepresentations on this application will constitute just cause for removal of arj~ppoir~ee. If you fail to answer all the questions, Council may not consider your application. --- General Application December 2008 Page 1 of 7 WHAT 1S YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ~~ _~~ ~~~ ~- ~~C~ r C`r . ~~~r ;~ `~ C~ ~ ~~ ` e=L -t ~ _ ` ~ ~~ ~C' C~l~ ~~; ~ l C Ct;~ 1 ~l r l cs1 ~7 ~`~SL~e S -_t-r-, c~ t ~' c:~ ~. ~ ~ v~ of ~~ C' -~ ~~,~~~~-, ~ ~~~~~~L~t ~~ "~s~x~C-fl v ~ . 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 thatSection 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 3~.5 of theCode 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 R COMMISSION? ~ 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 2008 Page 2 of 7 ~? ~~.®~,,~ BOARD, COMMISSION AND COMMITTEES ~.~ ~~'~ BUSINESS LISTING -.~.,:._ CITY OF IOWA CITY Name of City Board/Commission/Committee ~ ~~ ~ i 0 ,~ Date _ Name ~r i Q -~trlG~- 1~'~ C~2 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 (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (far example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS t~ C ~~~ tL, ~ Cv ~, ;~ : ~ , NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature,(jl1/~l.d~~Cl,bL~~~r91~'1` ~ Signature of parent/guardian (Youth Advisory Commission only): Address 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 2008 Page 3 of 7 City l~f Iowa City _ ~ r i ~~.:.®~x Advisory Board/Commission/Committee ~:~~"';~'~~ ,application Form ~-~- 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 appoint~~nent 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 RECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. (~ Advisory Board/Commission/Committee Name 7~~u~~ ~~ ~' S~ (~' C-~/'^ Nf ~ SS.)ra'9~` Term ~ ~ l0 ~ I~ 31 Youth Advisory Commission (shall not be more than 18 years of age at the time of-appltcatiorr) =g Narne of Iowa City High School or high school equivalent: C ~~ ~ ~~~- SC~~.~ ~~ ~ -ti Signature of parent/guardian: ~~tt~~.~_,-.~~``~`~ "SAME ~ f~~.X~rr,~'4`~ f~,~r~.r~~..c ~ ~ ~5 ,..., HOME ADDRESS ~' ~ t' ~ E~ s~ ~c~~ ~/°; i/c'. ZIP ;~:>:~~~,`~~~ 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? ~ ~ r.~ E'~'~ S OCCUPATION •~%~ EMPLOYER ,~/ ~ PHONE NUMBER: HOME' ,3~9 ~~~ °~ ~`~'_~ BUSINESS U/ .~ EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ~~~ f ~G.~~ r 'if°t' 4~A'~`~ ,.fit i1~j ~ ~ j~~fy{;c~f Cf~:~t ~ C 1 I ~~ ~,l`Q ~~' i~i't~ V G.~ i f~'3 c~. Ccy ~~ 1~~'~ ~' ~^-.) ~.~ _~ ti ~ ~~ ~ :~, a~ ~ 5 ~ ~ F r ~'~ ~ V ~~~~r~ r _l ~'~`1 '' ~~`{. et ^ v1. --C,.~ Jam"'-,'~~fi +~Y?~C' ~ =~ c?v r~ -~,F,~(.~~1_"`~ . ,.~n.~ t~, ~S ~ ~(~ ~^ 1 tom: ~ c f ~?v~.~~d ~. `~ ~~~~ _t(. ~Ir''~'~. ~ F vY~`'~a.f ~~ /~`tv'~~ l ;Y~~~.~~ ` Fi ! r e Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to a~~swer all the questions, Council may not consider your application. Genera! Application December 2008 Page 1 of 7 WHAT .S YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? ~. ~ ,. ~EC S ~ ~ C c~ l m ~ ~:. ~. ~ ~,~ ~' o {..!%, c.~ ~. -~ ~, m ~ I's~ l mss' ~ r~ ~h ~ ~..> -' -1 ~ S y~ '" ~ h:'~ WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? T ~ < ~ ~'{: `~~. ~E.~1A- ~ j V ~-~ 4 ( ~ ~-S ~ l V ~ ?~AY! (u~. l Sc~ V (~~ /~,, 5S j d+/l c~.'t' E ~ ~ ,~; f~~~~. ~- ~~vl c ~; ~ ems, ~, ~ p~~ , y j . 1 POTENTIAL CONFLICTS OF INTEREST .. Please identify any potential conflicts between membership on the advisory board and ~~ur 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 fcr funding from the City. "Affiliation" includes being a board member or employee of the agency.Other types ol~ affiliations must be examined on a case by case basis by the City Attorney's office. You should also knowthatSection 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 ofSection 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. JV 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 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 a~iswer all the questions, Council may not consider your application. General Application December 2008 Page 2 of 7 ~ r P BOARD, COMMISSION AND COMMITTEES ~~~'~ BUSINESS LISTING --~,_ CITY OF IOWA CITY z Name of City ~~~ .f Board/Commission/Committee ~~i;~ f ~~ ~~ ,~ So r~ y~- C.o MM~s si ~-'/~..- Date ~ .~ ~ ~ ~ ~(` i~ ,-~-~- N ame l`t I E..~._ ~~ %~MC~~4ti.s 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 (see page 6). List all businesses in which you, your spouse/domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stock!~;oldings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS t ! _ i , 1 .. ~ ,.yi1 ,~ ~ ` ;' ~~ 5 NO'!'E: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature ~t(.~1~~-~~~`Py Signature of parent/guardian (Youth Address~~~ ~~ E~~S~~~~n«~ ry Commission only):`~l~tic~,~~ ~`~!>~-ti'°- 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 2008 Page 3 of 7