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Home My WebLink About2006-02-13 Appointment ~ NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: AIRPORT COMMISSION One Vacancy - Unexpired Term Ending March 1, 2010 Duties: To exercise all the powers granted to cities and towns under Chapter 330 of the Code of Iowa, except the power to sell said airport. To annually certify the amount of taxes within the limitations of the Statutes of the State of Iowa to be levied for Airport purposes. All funds derived from taxation or otherwise for airport purposes shall be under the full and absolute control of the Airport Commission, deposited with the City Treasurer, and disbursed only on the written warrants or order of the Airport Commission. Iowa City-appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Airport Commission meets the second Thursday of each month at 5:45 p.m. Applications must be received by 5:00 p.m., Wednesday, February 8,2006. 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 Commission should be directed to Randy Hartwig, Airport Commission Chair at 337-2101. Airport Commission ATTENDANCE RECORD YEAR 2006 IMeolin Date) TERM 1/12 1/23 NAME EXP. Daniel Clay 3/1/08 --- OlE Randy Hartwig 3/1/09 X X Greg Farris 3/1/07 0 X John Staley 3/1/06 X X Howard Horan 3/1/08 X X KEY: X = Present o ~ Absent OlE ~ AbsentlExcused NM ~ No meeting --- ~ Not a Member I , 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: 0 Council Announcement Date: November 1, 2005; December 13, 2005; January 23, 2006 Application Deadline: Wednesday, 5:00 p.m., February 8,2006 Council Appointment Date: February 13, 2006 AIRPORT COMMISSION One Vacancy - Unexpired Term Ending March 1, 2010 (Carl Williams resigned) John Staley [RJ 314 Beldon Ave (Currently serving unexpired term) [RJ Denotes applicant completed the Confidential page of the application. February 8, 2006 TO: Mayor Wilburn and Members of the City Council RE: Application for Airport Commission Unexpired Term and Concurrent Resignation from Current Appointment Dear Friends, My current term as an Airport Commission member expires on March 1, 2006. At the time I applied, I anticipated a six year term, but, since the open position was for an unexpired term of a recently departed member, I have now served since November, 2003, or a little over two years. I remain interested in and committed to serving on the Airport Commission and since my current term will expire within the next month, I request appointment to the unexpired Airport Commissioner term ending March 1, 2010; and if so appointed, concurrently resign from my current appointment on the Commission. My completed application form accompanies this memo. Thank you for your consideration and support of this request. Sincerely, ~m. Staley, Ph.D. JHS:lmr Enclosure 6 "" = c=> ~s; C? "" ..." ,." -< txJ :-n C) I ----:r....., Q;) ~ ~(" , ~ _-< 1-'- ill n' -0 02'-~ 3: j--' </~. ~ \.J >: 0 0 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION APPLICATION FORM I ~ I ~~~~-.: ~~.,;'~ ..............-. CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 NAME Airport COIIIDission Youth Advisory Commission, Age on the date offiling:D Age 15 to 17 (or) Unexpired Tenn TERM' Ending March 1, . 2010 D Age 18 to 21 How long have you been a resident of Iowa City? OCCUPATION Hospital Administrator ...., (5 ~ ~.; 0 -.. -.=:: co 11 ,-;. I ._< i'~ co r-n 2!F22 52~0 0 <::::"."".... Is your home address (listed above) within the corporate limits of Iowa City? [] YeiJi DJio \D Approximately 38 years EMPLOYER Uofl Hospitals & Cli n; cs NAME John H. Staley Signature of parent/guardian if Age 15 to 17: HOME ADDRESS 314 Beldon Ave. PHONE NUMBER: HOME 337-3927 BUSINESS 356-2681 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: - Member of Airport Commission since November, 2003. - Over thirty years as a hospital executive including past administrative responsibility for the UIHC's Air Care Emergency Helicopter Program and frequent interaction with Iowa City Airport staff at that time. . Service on a number of association, community and other boards and committees including those of the Chamber of Commerce. Iowa Business Council Deputy Committee, United Presbyterian Home, Iowa Hospital Association-American Dental Association. 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 November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? As a current member of the Airport Commission, I am fully acquainted with the duties and responsibilities of a Commissioner, the issues and matters that have faced the Commission during my tenure and the issues and challenges that the Commission will face in the time ahead. I was involved in the development of the Airport's strategic plan and understand the goals set out for the Airport during the time of the plan and the obligations which the Airport and the Commission have to assuring that this vital community asset serves the needs of Iowa City. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? As a citizen of Iowa City and a current member of the Commission, I fully recognize that the Airport is a vital community asset. I am especially knowledgeable about the goals set for the Airport, its value to the many constituencies that rely on the Airport and the potential which the Airport offers to expand its contributions to the community. Given my professional responsibilities, I am also knowledgeable about the Airport's value to the UIHC's Air Care Emergency Helicopter Program, related EmergencyfTrauma Services, Transplant and other services and many other programs and air transportation and training needs of the University of Iowa. If appointed to continue as a member of the Commission, I would work collaboratively with other members to preserve and strengthen the Airport as a viable community resource drawing on experience as a Commissioner and that gained from substantial line and staff management positions which have included major operational, budgetary, personnel, communications and capital development responsibilities. POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory board and your personal interests, including financial interests and your duties to an employer. In particular, if you are applying to be a member of a board or commission which makes recommendations tothe City Council about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code oflowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about SEfstion 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. 0 ~ ~C) -r'l ....-- -' 1'""'1 NONE >::;: OJ Il '~. j 1,..- =i C 0:> iTl ::-', r:-, :r=- ~~"'\ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? II] Yes ~ '--' DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSlor1? D ~ [i] 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 November 2005 Page 2 of7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING 11 1 -,...- -IQ' f~tlai!:~~ ~... .....'- --..~ CiTY OF IOWA CiTY Name of City Board/Commission Airport Conmission Date February 8, 2006 Name John H. Staley Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none, BUSINESS NAME BUSINESS ADDRESS None . ....., 0 = "" "c>-(! -" ::r; --~ (T1 ~ ,..,-< w .-! I ~C co ::--n . . Q~ :x> (} ::Yo: <..^: - .. )> (II 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 parentiguar ian if Age 15 to 17: Address .3 L'f <g I ^ ~ t\. \H.. -::r- r I ::r::- A r ~ ~ V, ~ ~ I 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. General Application November 2005 Page 3 of7 I ~ j ~~~~'t -.::::......~IIIII~ ....,... ... CITY OF IOWA CITY~ MEMORANDUM Date: February 9,2006 To: Honorable Mayor and City Council From: Amy Correia, City Councilor Re: Youth Advisory Commission Membership Recommendations As the City Council Liaison to the Youth Advisory Commission, I was tasked to develop recommendations to the council on appointments of all 7 members. This was a daunting task. There were a total of 15 applications, with 10 applications for the four 15 to 17 year-old designated seats, and five applications for the three 18 to 21 year old seats. Over two days in January, Regenia Bailey and I met with 14 of the applicants. The following is my recommendation. This was a very difficult decision. Each applicant would make an outstanding Commission Member. I am confident that if you take my recommendations as a slate, or change my recommendations, that the first Youth Advisory Commission will make important contributions to Iowa City and the City Council by providing a direct youth voice and leadership to our body. Recommendations for 15 to 17 year olds: Two Year Terms January 1, 2006 - December 31,2007 1. Audrey Keranen Audrey is a student at West High. She is a member ofthe Coralville Public Library Teen Advisory Board, and helped to raise capitol from local business for the new facility. Audrey is also a member of the West High Newspaper staff. 2. Sara Ziegenhorn Sara is a student at City High. She is a member of the Chamber Youth Leadership Program, a City High Student Senate Representative, and volunteer at the Iowa City Public Library. One Year Terms January I, 2006 - December I. Subha Subramanian Subha is a student at West High. She was one of two youth coordinators at United Action for Youth that initiated the formation of the Youth Advisory Commission. She is involved with the West High student government and a member ofthe Chamber Youth Leadership Program. 2. Elyse Abboud Kamps Elyse is a student at West High. She is involved with the West High Gov Club and is a year book editor. She volunteers for HACAP and the Children's Miracle Network. Recommendations for 18 to 21 year olds: Two Year Terms January I, 2006 to December 31, 2007 1. Maison Bleam Maison is a student at the University ofIowa. During his senior year of high school he served as a Paige in the Iowa Legislature. He is involved in UI Student Government. 2. Jacqueline Stubbers Jackie is a student at the University ofIowa. As a high school student in Des Moines, she was involved with a youth advisory board to the United Way. She was a member ofthe debate team and currently serves as a judge for high school debate contests in Iowa. As a UI student, she has been involved in the organizing committee for Dance Marathon. One Year Term January I, 2006 to December 31, 2006 1. Michael Nelson Michael is a student at the University of Iowa. While in high school in the Quad Cities, he was a member of Teens for Tomorrow, a youth advisory group that granted funds to local service organizations. He also served as editor of his high school newspaper. \ \ ~ NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: YOUTH ADVISORY COMMISSION Four Vacancies - Two Year Terms January 1,2006 - December 31, 2007 Two (2) persons -Age 15 to 17 on the date of filing (1-10-06) Two (2) persons -Age 18 to 21 on the date of filing (1-10-06) Three Vacancies - One Year Term January 1,2006 - December 31, 2006 Two (2) persons - Age 15 to 17 on the date of filing (1-10-06) One (1) person - Age 18 to 21 on the date of filing (1-10-06) 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. All members of the Commission shall be residents of Iowa City and must be the required age on the date of filing. Said age requirements may be waived by the Council due to a lack of applicants. Meeting time and location to be determined by the Commission. Applications must be received by 5:00 p.m., Wednesday, January 4, 2006. 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.icaov.ora. Questions about the Iowa City Youth Advisory Commission should be directed to Marian Karr, City Clerk at 356-5041. 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: 0 Females: 0 Council Announcement Date: November 15, 2005 Application Deadline: Wednesday, 5:00 p.m., January 4,2006 Council Appointment Date: January 23, 2006 *** Said age requirements may be waived by the Council due to a lack of applicants. YOUTH ADVISORY COMMISSION Two Year Terms - AQe 15 to 17 January 1, 2006 - December 31, 2007 Two (2) persons - Age 15 to 17 on the date of filing Subha Subramanian lRl Audrey Keranen lRl 2468 Rushmore Dr 701 Manor Dr Ashley Gaeth lRl Mildred Henderson lRl 50 Rita Lyn Ct 1615 Crescent Nelly Provencal lRl 720 N Van Buren One Year Term - AQe 15 to 17 January 1, 2006 - December 31, 2006 Two (2) persons - Age 15 to 17 on the date of filing Subha Subramanian lRl Ryan Fell lRl 2468 Rushmore Dr 11 Bedford Ct Nelly Provencal lRl Jessica Loan lRl 720 N Van Buren 1204 Deerfield Dr Sarah Ziegenhorn lRl Elyse Abboud Kamps lRl 406 Reno St 2 Oak Park Ct Audrey Keranen lRl Mildred Henderson lRl 701 Manor Dr 1615 Crescent Caitlin Leehey lRl 2718 Jacque St [8] Denotes applicant completed the Confidential page of the application. CITY OF IOWA CITY ADVISORY BOARD/COMMISSION 'iPPLlCATION FORM J ~ 1 &~~~~tt ~~....~ ......_ 1 On OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 NAME Youth Advisorv Board TERM: 1 or 2 Youth Advisory Commission, Age on the date of filing:[l] Age 15 to 17 (or) 0 Age 18 to 21 Signature of parent/guardian if Age 15 to 17: \j. ';-h,.,/ NAME Subha Subramanian nOME ADDRESS 2468 Rushmore Drive Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 1 vear OCCUPATION Hiah School Student EMPLOYER PHONE NUMBER: HOME 319-354-3842 BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ZIP 52242 [l] Yes 0 No I assisted in the initiation of this commission, and I am very eager to be part of the experience that I helped plan out. Additionally, I am in the Chamber of Commerce Youth leadership Program, hold the Volunteer Coordinator position an the West High Student Senate Executive Board, am one of the two United Action for Youth Iowa City Youth Commission Coordinators, and serve on the Teen Advisory Board of the Coralville Public Library. These positions have given me opportunities to provide each organization with a voice representing the youth of the community. I have learned how to carry out the role of a leader efficiently and positively. Aside from leadership skills, I volunteer at the Ronald McDonald House, United Action for Youth, the University Hospitals and Clinics, and take part in most volunteer opportunities offered either through the school or community. These have given me the chance to hear a V;::IriAtv of nnininn~ ;::Ihout the low;:t ~itv C':nmmllnitv ArAR. Misrepresentations on this application will constitute just cause for removal of an appo~'r\ If ~ fail to answer all the questions, Council may not consider your application. );;;::::; is ,,'") ~'-'~ ~ -- -:J \. .' ,. .. ---.: '-, c-=: ......., r~_ -- c' ::z in Q=-.:'-j -. 1/ ",- /\ f\) 0 ~ " ~ Page 1 of7 General Application November 2005 - WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? The Advisory Board will promote the learning of govermental procedures, provide a partnership between youth and adults in the community, give a chance for youth to voice their opinions and help reform policies, and create a -ommunity that reflects both the needs of adults and youth. Additionally, four members will be of age 15-17 and two om the ages 18-21, which will ensure that a variety of viewpoints be present on the Board. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? The contributions that I can make to this Advisory Board include voicing opinions, connecting to the parts of the community that I reach out to on a regular basis, devoting as much time as I possibly can to make the Board successful, and helping the community through my perserverance. The Council will be able to visualize what a youth's dream of the community are and understand how youth view the community through the suggestions that I will bring forth from the youth to the Council. I like to think that my communication skills are one of my strengths, and I can use these communication skills to link the community and the Council. Furthermore, because I volunteer on a constant basis in the community, I will be able to see a variety of situations and problems that occur, which I would gladly report to the Council. Additionally, I can show the community what the Council and the Board have done to meet the citizen's needs. Time committment is a factor that I strongly believe in, for it is one of my biggest pet peeves. Therefore, I make it a priority to commit myself to any activity, and I think the Council will benefit from the devotion of time that I will give. Morever, I have been known to never give up on something that I think is just and right. I will never give up on a community issue if I believe that it is beneficial to the community and its citizens. These contributions will give the community a constructive impression and notion of the Board. POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membershi on the advisory board and your personal interests, including financial interests and your duties to an employer. I., particular, if you are applying to be a member of a board or commission which makes recommendations tothe ty 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 of the Code of low a generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy ofSeclion 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/A IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [l] Yes 0 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 0 Yes [l] No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) - 2! Misrepresentations on this application will constitute just cause for removal of an ap~f1lre. ~ou fail to answer all the questions, Council may not consider your application. );: -.:: is (-, -< ~ 11 General Application November 2005 Page 2 of 7 -< r . ! '- ) ....- ,--. "',. :3~{l ~x )> W -0 ::0: ~ C ill .;-, '..,J r- - BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING J! 1 .-,...= -4 f~q~1t -..::., ~.., ...,..- - CITY OF IOWA CITY Name of City Board/Commission Youth Advisory Board Date 11/20/2005 Name Subha Subramanian Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS N/A N/A NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature~ ~ vv-...rl '^ -Ulr:-- Signature of parent/guardian if Age 15 to 17: \j . rJ/ Address 2468 Rushmore Drive - General Application November 2005 Page 3 of7 ~.< r-:: iT; 07] ~x )> -0 ::x N o CITY OF IOWA CITY I ~ I . ADVISORY BOARD/COMMISSION FILED ;t:~~'t~ -..::..... _....me.... ""PPLlCATION FORM Z005 NOY 29 AM /0: 52- .. ~ CITY OF IOWA CITY CITY CLERK Individuals serving on Boards/Commissions play an importa n'a 5i 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 (:)e 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 NAME Youth Advisorv Commission Youth Advisory Commission, Age on the date 0 filing:!Zl Age 1 Signature of parent/guardian if Age 15 to 17.. . TERM: 2 vears D Age 18 to 21 . 'I\ME AShley Gaeth HOME ADDRESS 50 Rita Lvn Court, Iowa City, Iowa Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 16 years OCCUPATION Student at Iowa City Hi!1h School EMPLOYER PHONE NUMBER: HOME (319) 354-7151 BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ZIP 52245 o Yes D No I am a strong, responsible student involved in activities in and outside of school. I have been a member of my high school's volunteer and service club, Interact for three years and am a co-president of the club this year. Through that club I have gone on a service trip to a rural Mexico city. I also attended a Rotary sponsored leadership conference (RYLA) in 2004. I volunteered at Mercy Hospital through their Youth Volunteer program during the summer of 2004. I have been volunteering at United Action for Youth (UA Y) for five months and work to answer the teen help hotlines as well as other tasks in the Youth Center. This fall I attended the National Young Leaders Conference in Washington, D.C. where my leadership skills and interest in politics developed and grew. Misrepresentations on this application will constitute just cause for removal of <IIn appointee. If you fail to answer all the questions, Council may not consider your application. General Application November 2005 Page 1 of7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? This is a new Advisory Commission that will allow youth to have input on City Council decisions. This input will raise ''Ie awareness of all youth in Iowa City and encourage more interaction between youth and adults. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? I have a strong interest in politics and want to gain experience at a local level. I've also realized that youth in my community don1 seem to have an interest in local politics because there is no way they'can make an impact or even have their views known, I feel like this commission will create that opportunity and am excited to have a chance to become a part of it. J would contribute the leadership skills I have, but would also gain more leadership skills working with other youth in this commission and adults on City Council. I participate in music, clubs and sports at my high school so I feel that I have a good idea of the interests and concerns of my peers. As a member of this commission knowing these interests and concerns would be a very valuable contribution because knowing these would help me understand and explain opinions different from my own. I am anxious to be able to make an impact in my community and feel that being a member of this commission would give me a chance to expand on the impact I can make as a volunteer and make an impact on a completely different level. 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 of Section 362.5 is attached (see page 6). "" If you are uncertain whether a potential conflict of interest exists or have questions ab~ Sec~ 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. ::> 0 :z: .c;:- c::> n-< N r~l~ ::J'-, '-'> c<:~~ m - Q:1 ~ (:::J O~ = ~ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [Z] Yes 0 ~ ~ DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 0 Yes [Z] 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 November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I! 1 ;:;;~.;.-.:,... f~W;!l:'"t. -.;::.... "'l1li''- ....... .. CITY OF IOWA CITY Name of City Board/Commission Youth Advisory Commission Date 11/21/2005 Name Ashley Gaeth Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME. BUSINESS ADDRESS ~""'^ Ir, LA" ~O'il Hi-I..IA....IA\Jp I;.,.."'(';~' IA .-~~j1.lO. <7 ./' ~ 0 g: ...:;:\. } . )> ==i ~ 11 NOTE: A new form must be completed if the above information changes or an own~i'tifi inljuestii>- acquired in an additional business. -j 0 u:> :-n :-<\ I I . ", ~ 0 O;Td '-- . c.n Applicant Signature Signature of parent/guardian If Age 15 to 17: Address 50 Rita L n Court, Iowa Ci 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. General Application November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION \PPLlCATION FORM ,~ I f~~~*t ",,-.. ......, ......~ CiTY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. This form may be filled out manually (please use a black ink pen), typewritten, or electronically (PDF). Retum 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 NAME 'cA TEaM: r-.> = = ...- Youth Advisory Commission, Age on the date of filing: jgJ Age 15 to 17 (or) Signature of parent/guardian if Age 15 to 17:~'jl.lIt}\l~ ~ 1e:;R>2m ---jC. -.J i .-<r rll rn -g -:IJ ::J: I r- ~ w r- NAME ~ R..O-J EN'(..f\ L N e..\'! rlOME ADDRESS --'':UJ N.'J 0..(\ B:.,^~e<'\ 3:'",,\JJo. G...-t; Is your home address (listed above) within the corporate limits of Iowa City? C c:J:: How long have you been a resident of Iowa ity? .2..: 1 ~".....s OCCUPATION S\ \J- ~~ '" EMPLOYER PHONE NUMBER: HOME '?N" ~ '5 \ 44 S lS BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ZIP .t8J Yes 512~5 ONO 4\- '\ \-h~ c:: C~ oJ & __ -J c~~'" ---""-",,'... \eo <0"",- ,,::.:.-C-J-, ~\\.-.-.. _ 0 \cI. ~ _\ CA-\ ~ '---' '''""t ~.... p.."" -. ' .~':\ ';,. ~,~.. " .?, ~ S ". --'-- ~ ~'---r-c..Y.... c.Jc'~ -V\, \- \L, """..;>~ \'.. ,,\,_ \-L Dc~ , > \ 0 c~ \~ 1,-" ~ Misrepresentations on this application will constitute just cause for removal oif an appointee. If you fail to answer all the questions, Council may not consider your application. ' General Application November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? . l ~-e'r$~~ '\\.-..s.....~ ~ "Ibv.--u.... Mv\"t:,u~ ~yY'\''''S\~,", \5 -to ~""M=4- '^-h<\~~~J....,~,,\ 'i\ Q-....)c-.~~s S cR- ~......,.--- CA.*<> ~ ""~" ~""'':'t~ -n... ,\~'-Jo-C~./ CA.,""^- --'o-......~ ~,~ ~K:>'""--~ he...,-~s I-Yc......""-<L ~~c.-,"" \.""c--.~ C. "->-r-- L-er",-,,,-:) -\~ c&.. ~.-::;, WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? """l -'(}-.:\y-..~ ~ "'-~ ':S""'<::>~ ~~5h,-~ S~,\...\...S ......)',6- l ""-~ "'-- ':J"""'~ \,S~~ i. "'- C)"",,,.l.... ""~~. ""L '\)-.\C'\~ -\--h.",-s, ,-^--"",~d.-... k ","V"- '-.,,",~re.~"':') ~~>;.\.~~......... ~ f'\, 00'"\.^ -\>-..."-.\- '"l L=....J.....~ 't,e ""- b, \ C~\:.~'<;)'" \-0 \-'e\'~\~3 ~yf'\u..,,\c...--\\"'''' re \~~"<::'r--S k~ ~ --A-'"'--\.~ <<\ ~t> '^- """ b~ -:I..c.....:>-... c..~. A \~-c> "'J \.....""3.- J-.= ~""'"" ~\r<<- ~ ~~~'0 ~ ;;:.. c.-cJ""\. ,""Co..x........... q....'-^-'-L:--~::, ~_ v....'\\.., '&-\:y-,v-'<- ~. "'-~'-""~~ ~\"..c...~ ~ .l\,>~"-"",--~ ,,<, oU"~ -....:::,---~ ~~"'"3.- <:__'<"'-.., 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 memberof a board or commission which makes recommendations tothe ":ity Council about the allocation of City funds, please list any present affiliation$ you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). _ g . 0 ~ If you are uncertain whether a potential conflict of interest exists or have questions ~ S~on 362.5 of theCode of Iowa, please contact the City Attomey's office at 356-5030. ~ " =:!J ,.--" I .- ----Ie .... IT] :<~ -u 0 -T :x ~~ r ' :;:;: w IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~ Yes 0 No . DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 0 Yes .:KJ No (It has been Council policy not to permit an individual to serve on two Boards or Commi~sions 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 November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEE$ BUSINESS LISTING I! I ;t~~~*t -..;::.... ..ai' ........~ l CiTY OF IOWA CiTY Name of City Board/Commission '->--~ B~e.Q..~ Date ~~ Name ~CY'.J ~N CI Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6), List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINeSS ADDRESS /' / f /' \ / ...., , ~ - = \ \\ \ \' Sr> ~ ,",I \ J>--j ~ 11 U~ '.. r- :<r' ~ m / / n;:D :z U / ~. .. .;:" 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 parenvguard. ian if Age 15 to 17: ~~" \"I"~H'" - Address 1:l..<:l N, \[0.." <?--...n.e." ,::>'-"''^ C..",,-, :s:.~ :;2.2.<15 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 November 2005 Page 3 of 7 CI1Y OF IOWA CITY ADVISORY BOARD/COMMISSION ,. oPLlCATION FORM I ~ I -~=-'IiQ'... ;t~<ii~~ -.;;::.... -~, ...,.a.a- CiTY OF IOWA CiTY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpillid volunteers. This form may be filled out manually (please use a black ink pen), typewritten, or electronicallly (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 "CONFIDENl[IAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDeRED FOR ANY VACANCY DURING THAT TIME. ADVISORY BOARD/COMMISSION NAME~~ Ad\lisa.r'"f Co-~icSi"'1 TERM: 1/1/0/# - 12/31/(j~ Youth Ad"~'Y Commlos'o.. Age '" ~o d,le 01,"g~ [g] Ago 15 10 17 (<>) . 0 Ago 1810 21 Signature of parent/guardian if Age 15 to 17: fJf~~ ~?t ~ A . NAME 8a'('""C).h ?,.e~flArIv-.oV",^ I .v1E ADDRESS !-to ltl ~.r ~ C\ ~+ Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? I 2. 'f p ~rs OCCUPATION ---.-Hlf'^ ~c...\"\"" \ .S\-ud.e.~ +- EMPLOYER PHONE NUMBER: HOME(31Clt)"3 5'-1 - g,., g BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ZIP ~Yes S,:2...'15 ONo . /'^.e..",,-\oe..v- CJf- +vte. c..~e...r of- t.o'^"-V'I\.~ '(~\)~ :~k.lp ~~.", · 2. ie-a.,,"> e.~.e.c..+-e..o\ S1-\)d-t-V\..-\- &e..lI'\o.tL ~(;lr.e.s~-to-.t\.\ML c:oLt- u"""t ~ · "\JoluV\."\ -<e$'" eM- c.\""i'S>,.... L-e..,^~ O-V"\d. 1>$Io~.<:...- 1-~1II>v-c..~ (I'tr l!.a,,":) · CoV'\se:\c.V'\T\CU$ $t-Ud.~ (?..,Io G'PA) I =u,...,.o\.........,L ,v.. S~'!o 't. MtJ~i~ . M.~L\r ~ Cl~ H.\.~ :Lv\-\LV-o..c:.:t""" D~\Ii.~- Q.~Io. o """ ~ : --! r-r, Misrepresentations on this application will constitute just cause for removal of ~n appo@~ If @J failT to answer all the questions, Council may not consider your application. _-:J Q c.v F.=: , '- i-n _ i-r-: l ,eral Application November 2005 ........., .:..~,-. ~A )S: -. 0 - " Page 1 of 7 c.n -../ WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? -r~ \~ INl-s 'Q.Il.-'!.Y"' CX-~~ -fc.>r ~........ ?.-o""'-O"tiCA'" <>-IN:lL 0(- ::t~ U::-t ~ lo c..o-\ ~..su-e,> o-.~ 'tQ.u*"", .ML~CY'5o. c;I{2 "'--V\It... c..Ovv-.l't-t--e... o-(cl (V\.. Wlo..\Ll~ d.~~.q;.\0^s. ~~ ~y- pe...ex-s . WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ::r: GLW\.. '-IVI'"'-(. \.\r\.~~~ ,~ \oCD..l i~l>\l e~ c.f'o......'t1:~ or V'\.Ov.) o-.v--d. ~~ (). ,?o-"",",c.~\:~..r l,^,""",~~ ,,""- ~c.\f'UrV\~. :r:: ~ ~ S~~ \~a.d.lur 'i;>'-'r Co...v'\ \..\jov-~ ~ w-U.\ \.U \ ~ o~.e. v-s, o...N"o... c:J.-VV". c..,,~o-'" ~. ~ Wo...V\,;(- i-<:l. ~. 0-\1". CL~~ ",^~Y;;IUr .~ w\.'-{ c.o"'^W\.~'+:-r o-..~ '0,- ~~ C>\f\- ~ o.d.\.lt~or'1 bcou.t-d.. 'I- eel-V\. i",ure."'-\-L rn l OI,)JV'\ IJ \ -e..v.o...\. cJF o-c.n\) \ \-\.{ o-v"I6. \ y..\lO \.v~~ ~ \A\ '-'- Y\.~f \~ o~ex5 0-1/"\0.. \ V\~V" .('C1'5 ( "'"3 c..o\M-\M.-UV"I..l \:-\..f Cl.\J.lO.n~ cz.~ \V'\. o~e"$. :r:- oJ.~ 'o.L\.\~v-<L Wl'{ ~v-K- e.~',,- J..y.,d.. O~o..I'U~"'" $It-l"\.\... u>ol.> lei.. ~-tv-\ bU-\"L \.VLL\ 1t::> t-V'-L. be::> av-d. . POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory I:!oard and your personal interests,including financial interests and your duties to an employer. In particular, if you are applying to be a member of a board or commission which makElS recommendations tothe r ., Council about the allocation of City funds, please list any present affiliations yqu have with agenciesthat .."ply for funding from the City. "Affiliation' includes being a board member or emp~oyee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney'~ office. You should also know that Section 362.5 of the Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. V>. copy of Section 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. I No ,"",H~ * ,~~,,~ I IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? l8J Yes D No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? DYes Ig] No (It has been Council policy not to permit an individual to serve on two Boards or Commissiqns at the same time.) r:: "-> :;?:,....., ~ Misrepresentations on this application will constitute just cause for removal of an appo~ If JAlJl fail to answer all the questions, Council may not consider your application. 0 --< CJ, ==i r, ;-: -:.. 6$ ~ ITI ..,.. r---, -<::: '-, \.J $ ~ Page 2 of 7 , .leral Application November 2005 c.n -.. BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ I !;~~ ~... ......'- ........ CITY OF IOWA CITY Name of City Board/Commission ~o\J t-v-. ~VtSCN'j CoWWV'l_.~..~~~ Date \ '2..."" 1- 0,5 Name $0.Y"'0....\--. Zi.fl?t^'\r.J:!,v-v-. Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 662.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if appliq:ant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINES$ ADDRESS A //:).(J7.. , , . 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 paren Address u rdian if Age 15 to 17: I -4oCo ReM S-t -:c"..,"'- G..-n.r ~;l.4-~ / ) ~ Misrepresentations on this application will constitute just cause for removal of an app@t~. If~U f"J to answer all the questions, Council may not consider your application. .=<! P 'm: rn -0 ~ '-'A- _ - ~ U1 -.I vi..--- , .leral Application November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION FILED APPLICATION FORM 2005 DEe 2/ PM 2: 22 I ~ I -,...= -~ :t~~;!:*t -..;::..... '!W''''''~ ~aM CITY OF IOWA CITY CI'T'\/ (\1 I" -. / 1 L,Lt: Individuals serving on Boards/Commissions play an impor Iii dJQ\4qthe 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 NAME \/L V + VI A{hn..:.c {I ~ ((\ IV\ l'YIi ";;,OlnERM I Youth Advisory Commission, Age on the date of filing:1)(j Age 15 to 17 (or) 0 Age 18 to 21 I Signature of parent/guardian if Age 15 to 17: 9'CV ~-~""I.---<- I II,ME A uc\ n., y I<P Ie=) neVI HOME ADDRESS 70 I /VljH'\n( D( I vi? Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? _f I' I) LLt \/ e II if ') OCCUPATION EMPLOYER ZIP 52 z t./<C ~Yes 0 No ~ C.~i\vl(u- PHONE NUMBER HOME 3'SY - LrT 50 GU3IN[3:J (,1.\ - 4'11 ~ EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION Cf1nluCl\e.fu\o\lt.lib'ro..:n" TeeVl UIS0'\\__ ~l'C. - we YY'ee.t fY101'\..tvl.~ 10 d.I.Sc\J;;s VlQ.U)I~ 6He\t1.COl'lreren(j~ ()Ji1+l~O-.<i \)\tr ~ ("o.uP) n,endS: ~~~I a:t.-./4tl co t \(),J0~ 01'\ icl1.c'S., ~ct-~ we... t'ii'\(::'Y!ed ~~ ePG CQPitQl ~O\ t--) Ll yQar--\ovn e(fbl-t'roY-(U~ ~2VV\,\lPV1 f&- ~ V\d.W 11 bmr\.j. ~ t.UJYl::'ec!.Jn (i e UVl,\'t::, to\-Q\'k- to 10::0.\ 'DJ3[~ cl;ovt- m''s'Yl3 mo~1 \led txL\cesa.-I-esa.. e.\IaY\,ts o.\'a 12o.r wC\Shes,a..ncl ~ we*, tv\L~\i2.cls m s~+ reroVQhtms. ~ vciu l( \0 to-(( ,r:a.ch €C3Y" W~ llnlCE' .fW.- teen S II fY\l/1er \Z.eCld.\l1~ fnJg rCU'I1I, V\ . - + - , I. 1-\' C'&SS-( n.tl" ~YeUCl 8 vo uVlte€r a. VYI '+ 4. Vera. e />.n WCY' 0-. (" f'r> ~ S\-O..n-; I Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail [I to answer all the questions, Council may not consider your application. i General Application November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I :r Ia1lXl),\-floi- It Is 0- \'lQUJ L'ot'N\1f-Hee crm\ed tv 9 T~ ~'!9f=Orle Cl VOiCe I VI Il'l1pOYoHV'H Ol't{) VV/,Q>>:<<s:C aYYJ well lUlnre cf-fVte. r~OflSlbllllie; 'H1at i COWle- a1~ w\'\i1 tfij, f>os+ ctY1d ~ u..ll\l,~ -iD ~t-~jokJd~. , WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? t feel ~at '5b"It-s r VlaAJe JeayrJet1/Y) ~t-e~!"Nlces huse braquTI tJ1J rand enh anced '~5fr~t charad-er/wcs fhctf J frJS&J:J: Jea.dersh'A pe-tse~teraY1e.e/ rtea/Ylwork.j logic) and mtf;f t'rrtpPtanfoP I all afl o~ mind. f3t.j wt1Yb-i,,:,q ff!I: 'HlQ Oi>m//)fl/e Lihrar4 (api/Cdpr~i I ~Ylid eierne..J'lAs}elf VtJ r0nClraSfr;Q cv'd ~6l1aJi'!6 SHlls : abi/itq m ./ creMe ct bV5i~ pfaJ1/6f3aJl'&e ,ClfY6tessim:J ~h{)jdress 5.slK'C:~> gatY/, tfifl aH~oYl tJF(l.f1 cwdt~ Clfd w(JY't:: /flC{ D'!Iee7Cr;1 (Vr7t5~ 01- hflU. r a./SD leClr rwt f1NXSsafL/ peDple skJl/Ls .}ha.t- r /!LJ['t/ brt'J18 to rovftl ClfVlmltfe.e.S ame4.8er meontri!ov!e IdMs/ 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. ,,1 particular, if you are applying to be a member of a board or commission which makes recommendations tothe City Council about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). If you are uncertain whether a potential confiict 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. ~ ):>0 CJ --l fT1 o -< ;:; 11 --1 r. I- I --<, I .- ~ ......- IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 1XI Yes lij:fu:;; 0 DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSIcJ!;f? ~es !XI 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 November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ I -~=- -.:'1 !~ai!:'t ~~_ODJ' ~~ CITY OF IOWA CITY Name of City , . Board/Commission \/ (;It "lh AA \11<,(,(\ \ (Ii VV\VV\\ SS,\ffi1 Date --Of'(!, \ Cf . I Name ALdoyJ<f:711.nerl Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor. partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS f1/l111 VJ 11M i I 0 = = ~O ~ ..... -< ~~ II -j~) - ; -, - : Ii _rTl :::;! 0 NOTE: A new form must be completed if the above information changes or <!In owne~ int~stis acquired in an additional business. )> N N Applicant Signature at ut'7Jtyft ~1({ /'li?..tl . . . Signature of parent/guardian if ge 15 to 17: ~;:> Address '1(\ N\CUJO r pr. :Lc'LLCl (ill c;;;u.'/(.., ~ .> ~ . I Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail I to answer all the questions, Council may not consider your application. General Application November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION APPLICATION FORM I ~ I :o:::~:._~... :t~w!:"t. ""-:' ......., ......... a. CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 NAME YOUTH ADVISORY COMMISSION TERM: 1 vear Youth Advisory Commission, Age on the date of filing: [l] Age 15 to 17 (or) c:::g.ge 1 ~ 21 "'(\ ~ So Signature of parent/guardian if Age 15 to 17: f ' , (~ .. ~ '1> ~ F?, a . ,. \.J II r-... -..~ --j C -.J i 'AME Caitlin Colleen Leehey ---<i., "" :n =::c' :% l~ U~. V HOME ADDRESS 2718 Jacque Street Iowa City, Iowa *'5224~ Is your home address (listed above) within the corporate limits of Iowa City? [l] Yes 0130 How long have you been a resident of Iowa City? 9 years OCCUPATION West Hiqh Junior/part time work w chiropractor EMPLOYER Coralville Chiropractor PHONE NUMBER: HOME 351-2597 BUSINESS 430-8456 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Governement Club West High, American Business Persons Club West High, Leader of atheltic spirit for varsity football, basketball and wrestling with cheerleading. Volunteer in City Council election campaigns. Member of West High Chapter of National Honor Society. Honor roll each tri West High, have attended City Council meetings, Attended WRAC workshop in council chambers Oct. 05, "How to talk to your elected officials." Have attended EPW (Electing Progressive Women), meetings, Registered for EMILY's List Political Opportunity Program training in Des Moines on Jan. 6th and 7th 06. Act as leader in government classes at West High School and am effective in recruiting others to attend political events such as the WRAC training. Have spoken with Sup Neuzil to arrange a job shadow day. Plan to apply for Senate/House page posistion for 07session/discussion with local elected officials. 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 ApplicatioD November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? To work as a Iiason between the IC youth and the IC council promoting an understanding and awareness of Iowa ~ity. This will allow a group of youth to help make decisions concerning them and their peers. It will provise an _pportunity for youth members to hone and expand on their leadership skills. The board would provide a forum to develop partnerships between the council and the youth and increase communications. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE' TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? I am a good communicator with good listening as well as speaking skills. I am interested in my community and have been effective in generating interest about the community among my peers. I am an analytical thinker and a good problem solver, approaching problems thoughtfully from all angles. These skills along with a "can do" altitude and enthusiasm would work well for me serving on the board. In addition to having an ability to generate enthusiasm among my peers I am also able to elicit cooperation for new ideas and projects. I am able to increase awareness of local issues. I have functioned as a productive team member when working on group projects and always take my role seriously. I know how to relate well with youth and adults alike. I have had an "adult job" since I was 14 years old, working in a chiropractors office I have contact with a diverse group of people every week. I work as a young professional in dealing with the patients, medical personal and insurance companies. In school I am respected by my peers and teachers for being an empathetic individual; able to see things from others perspectives. I am considered to have wisdom and good judgment. I care about people and my community and have a passion to learn more about how to impact my concerns positively. The Youth Advisory Board would be a good experience for me personally to gain the information and develop the skills necessary to serve the community in a proactive way. 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 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 of Section 362.5 is attached (see page 6). '" - = If you are uncertain whether a potential conflict of interest exists or have questions ~!!) See&n 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. j> _I ~ D N -..j '. ::-.lC ...-<r--"" m O::"fJ ;EA :x:.. ::r '.0 r- m o J:""' IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [Z] Yes No W DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? DYes [Z] 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 November 2005 Page 2 of7 __.__~~_u___.~_______._______._.."__'"~,,________._.______ BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ 1 ~~~~-.: -..;:..... .-...," ...,..~ CITY OF IOWA CITY Name of City Board/Commission YOUTH ADVISORY COMMISSION Date 12/22/2005 Name Caitlin Colleen Leehey Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS '!i\,.. .JJ ~ . ~ ;;:;; j;: "-; ~ -n -"4 n-< N ~ ~I' hi . r . ;:=:;:0 :ll: lJ ::? "., \D ~ .J.>' W NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature i,~W Signature of parent/guardian I Age 15 to 17: Address 2718 Jacque Street Iowa City, Iowa W\r~ Q"\;~C~ 0, ~ Misrepresentations on this application will constitut~ just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application November 2005 Page 3 of 7 CiTY OF IOWA CITY ADVISORY BOARD/COMMISSION - PPLlCATION FORM I ~ j !~~~Ilf: -..::;::.... "IIII'~ ..,.. - CiTY OF IOWA CiTY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 NAME Youth Advisorv Board TERM: 1 vear Youth Advisory Commission, Age on the date of filing: [l] Age 15 t ~ a. Signature of parent/guardian if Age 15 to 17: 17 (or) ~e 18ge 21 -s: "'" ~O <- ~ --; ;c. 0---':" ---.;r-, c....> ~-<r m """ 022 :x <:: /'~, ii> 5224[ [llYes []No ; m c:; "'ME Ryan Fell HOME ADDRESS 11 Bedford Court Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 16 years OCCUPATION student PHONE NUMBER: HOME 319-338-7920 EMPLOYER BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I have been a member of student govemment since I was in elementary school. This experience has made me very interested in politics and working to try to satisfy all types of people. I enjoy working with people and love helping in the community in any way I can. I enjoy volunteering and have volunteered in Iowa City at Shelter House and the food bank. Most of the volunteer work I have done has been with Special Olympics. I started volunteering as a chaperone for Special Olympics when I was in 7th grade. I feel like this is one thing that has formed who I am today. I not only get to watch, encourage and be a friend to kids that don't always have that many friends, but I get to grow as a person through helping. 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 November 2005 Page 1 of7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? The Iowa City Council established the youth advisory commission in order to have a better understanding of the city's youth. The commission will be able to select a few youth to make decisions concerning youth in the community in jer to try and help communication between the youth and adults in Iowa City. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? I have a good understanding of the youth my age and the diversities of youth in a community like Iowa City. I will represent the youth of Iowa City by presenting both my opinions and theirs. I will not be afraid to express why I think something would be good or bad for the youth of Iowa City or how I think decisions might affect both youth and the community as a whole. ,...., = = C"' '- ,.,.. Z I W o ~O >'-c -' O' --.n _<r--- - r-r1, -'>> 0":- ~^ 3:'; 11 1- m r-':'1- V" ,.,. :x Ul 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. )articular, if you are applying to be a member of a board or commission which makes recommendations tothe City Council about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency.Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attomey's office at 356-5030. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? DYes [l] No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? DYes [l] 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 November 2005 Page 2 of? BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I! 1 (~~~-'::t -..::,.... ..l1li.' ...,...~ CITY OF IOWA CITY Name of City Board/Commission Youth Advisory Board Date 12/21/2005 Name Ryan Fell Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS AQ;QRES~ v\~Q _ ::;:" "" . P-j :l> 1'1 2: '-" -, /, .r i :<r:;:: :>>- iTI O~ -" U ~ -. en NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature K-z.. Signature of parent/gu Ian if Age 15 to 17: Address 11 Bedford Court 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 November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARDlCOMMISSION 'PPUCATION FORM I ~ 1 i~~-':~ ~.. .~ ...,..- CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications dl,lring 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). Retum 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 NAME Youth Advisorv Commission TERM:1vear Youth Advisory Commission, Age on the date of filing: III Age 15 to 17 (or) yJiUJ ~Af o Age 18to21 Signature of parent/guardian if Age 15 to 17: NAME Jessica Loan .-fOME ADDRESS 1204 Deerfield Dr., Iowa City, IA ZIP 52246 III Yes 0 No Is your home address Oisted above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 15 years OCCUPATION High School Student EMPLOYER PHONE NUMBER: HOME (319)-351-1254 BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I am currently in Business Professionals of America at West High School and I think the skills I learn in this organization will help me be a better member of the advisory board. I have shown dedication to my school work. I had a 4.0 grade point average at Northwest Junior High, and currently have a 4.0 GPA at West High. I am also involved in sports and music at West High School, which has helped me develop my tiline management skills and has made me more responsible. I care about what happens in Iowa City, and I would like to see more activities and opportunities for youth. 6 '" = "'" ;J;o 0-. . ---' --=- ~J . '_1 Misrepresentations on this application will constitute just cause for removal of an app.p!!Lbee. ~otifiil to answer all the questions, Council may not consider your application. ~ h: '"" in o~ :Jc r-, "'- '<T General Application November 2005 p - Page 1 of7 '-J WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? The Yourh Advisory Board will help adults and youth communicate ideas, and will help youth become more aware about afairs involving the Iowa City Community. The board will primarily communicate their ideas and help to make decisions involving fellow youth in the area. This board will help develop very valuable leadership skills and is a Jreat opportunity for teens and young adults to get involved. A position on this board will require much dedication but in the end, will be very rewarding for the individual as well as the community. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? I am a very ambitious teen, and I feel that it is very important to be involved in the communtiy. I like to help make important decisions, and I see myself as a very good leader. I am organized, respectful, and very responsibe, which I believe will be very important qualities in a member of the board. I like to hear everybody's opinions and make educated decisions based on what most people in the area want. I will enjoy communicating with the adults of the community as well as the other youth, and I would also be very enthusiastic about informing the rest of the Iowa City youth about what is going on in the Iowa City area. Many times youth in the area are not as involved and infonned about matters in the area, and I believe by helping them become more infanned, we can improve the overall feedback and energy from all of the youth in the area. I am already involved in many school related functions, and if I can connect my peers to the adults of Iowa City, in the end, I think this will influence decision making UMrthe Iowa City area in a very positive way. III POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory board and your personal interests,induding 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" indudes 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 Attorn~y's office. You should also know that 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 can think of. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? IZJ Yes 0 N..Q ~ DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? ~ Ye~ IZJ No (It has been Council policy not to permit an individual to serve on two Boards or CommiSSions at me ~"e51e.>-n o I - Misrepresentations on this application will constitute just cause for removal of an appQ~iee. I~u ~ to answer all the questions, Council may not consider your application. ~ ~ r:? .....J General Application November 2005 -.A Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ I f~4~'t~ -.;;;:.... ...., ..... - CITY OF IOWA CITY Name of City Board/Commission Youth Advisory Commission Date 01/()312006 Name Jessica Loan Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). Ustall businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17. have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate ifthere are none. BUSINESS NAME BUSINESS ADDRESS My father is a farmer 2237 Rohret Rd. SW, Oxford, IA 52322 ::;:; ~ ~ )>-i ~ -n 0"--:'" I r-:- :<;0- m ;=:;:'d :l:: C"J ~...-, N .- -.I NOTE: A new form must be completed if the above information changes or ~n ownership interestis ".,,"" · '" oddI """'~ 7j( ~ '. . /, Applicant Signature LMLCW,.. O(JIL ""',_ of parenllg~ n;" . Ago 15 ~, ~ ~Al Address 1204 Deerfield Dr., 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. General Application November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSIOr-FILED r\PPLlCATION FORM 2006 Ji\~! - 4 PI-I I: 2 I 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 NAME I ", t h TERM: Youth Advisory Commission, Age on the date offiling:~Age 15 to 17 r) DAge 18 to 21 Signature of parent/guardian if Age 15 to 17: ~ " ~l/ ~k . " ~ME 54jS~ ~id KflfYlp S HOME ADDRESS L DC:!$ llitk. ('r:\A r-t ZIP 512 tt it Is your home address (listed above) within the corporate limits of Iowa City? 1S(J Yes D No How long have you been a resident of Iowa City? -l't I,YJ,(,\ s tSi ii L.l hi \ -H ~ OCCUPATION <-Sn~lfl;C 'EMPLOYER PHONE NUMBER: HOME (~\q) Sill'" 4.ill BUSIII...:,::, cd I (~I'1) b ~I - '3,;Zf:: '7 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: - V Ill- 0 .l~idJ.I\/t of NoH \...WVH JWtl(;/'l. 1-111311 -P(Q,~i(.{u'\+ of- Ltd+ \"'h~Jh .scnca!'s 6c;VCll'u:J - NCdltno.J Hn\cr ~(;Clc:rlj rY\.l'X'(\.-Y.)-C'.(' - HAU=r(J VvILUltQ.LC CI1-,lc:.lv.el1.'s mirtzL\'<" N\'.t'\,vorK \'0 I u,vtu y- - We~1- l-hqh t.;}ittr'b(.I{J/i:. k'tLd:ef' - 2nd... IJjctCic . ItJG'Ck wri-j(r . SI:.-ncl(' I ~'Y\e.itPJY\ ') - ClUSt{UXUYIS C'i-h 2lnSfv p 11t,\.-CLICl (Uel) 0-.cip,"-"tt -Va."ic1-LS j'Ob shNiNv'''tg C'i ij-l$Ll\ (ct..lctor r4{ll:L~r,ff)(lr \U.hY~, ~aLfi-k ,({Ute1) I .. I' j, 'L....- -un CnulU c//,1.tStlCNy:...,f'- I u. 'i lV' , , . '.' 'Li"e:.. --I ",. v ':.J 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 November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? L tml,(;ti'lCc:t -1\'\)_:;' h LL brcu"VL ni.~L'j )(l,(\{,yLubv{.. beLl-rec- fer t1~J Ll'h:Jfh(cl:: Ail DI1XGj SW_Lt -lll0nlU-l>-+ qC1-Cth C+ lCl,UL en;) icr Ii':, rnlrnber5, ,1tru.~u :JI~ d: (CUI vYlecltc, CrttLt ~h0,x'1CS 1\'"\ CLc'" Cl'+tj lircl kill f'J."dllvt Il.lLL' jllSI0~n:~ \::fr (1'11. Ct:' :"o( \ ,'~\" "-,, , I W17kld- ' 1'.uL I ''1''- .-fi'U ' blYLrcL, WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? ,- (CLll ~li(ViJ -1HC j{K1V7t(tlV'- c,{ fU~J"' SOlLC{tn/1jC1A_h, tv tiLL b:(U'(( wh)\L S'\\ \ \ '\-.:\-LLL *"'j 'fI ~ p:("JlLloJ, Ix.Us,}'S [\..led: m.orc...ls of -+hi, n~dIL'-h.j ~" IOILh Ghcuu. 'T c.RI\.. \ofiY\Cj tl..- '(XU-S\bYl i\:l\- #uc 't'Y\.jMDYQrV\.tf\;\; at #~ 1uwn tllCcot 1: LLGLI ICukd... ih. G\Y\.dc. W~\L I telA Wilt,; blA-t( L"- vc,UA - ml,(,\C'ucl, (jtt.cLtIVc. er'JCLl'uL~(I:., (j1-L*'ilcl~ \ f(\c-tivtLoI-e'" cu-~ Q./Ytf)\1oj:$. pt.'SlJrlGLGtl-J -to L\.. fovcUol kVil.....-t Sh<;.'\AJ.Ol k:>< ncitu'ntj IL,,\- '-::(tbLl Ind. 'jOViU'NYtQ.n;t c.>J1d. c.cYYVY1-UxU-lLJ ;n,'WI~'N.n;I- '\Yl\T ",-t'~1wD v~~y _ " (ll- ~$r+cu'\' -\Yu~thcL-t w,l (di~Cn;\ s\ Vl'lAlcl \;.>L W\ivCIVw.. h T 1r<CM,'l 0. \)cL..'~lbllf< fJ:MtiC) o...-.J \('-'-01 C4cd f'(dr tr-<R-!--(YLQ..(l::l of cell o...l~( JU'1~ n~..ht'i, r: ~U'L l7ri~ b1YCrq jJe,l.:tiw ,c,l>t'!. Itl ll~~ I'S",-C:'> cud pu.:l ,YV-J ~lLC'-I'l w.J "I,,,,lej U4or+ \\1:;\0 1hjY " -.:r ~li.lvC (ll''' n h-t. :r will \-;)1\'('<1 toy)i'r\Aon. tYlV"YcJ...\ o..n.d. ~o...+<'-G\ Inpvd- -rc .fh;" bOo..l(,L i.~ ~v..,--\<:.c '. ly"n,.IJ",Sh"I)-:['11 \;;nMcj , POTENTIAL CONFLICTS OF INTEREST cltclitO...tlO1I. \Dl1(L~, (utA '(UPQ.Ct. '.t11(>Y\lllAC r(.,~.tr'\r\y Please identify any potential conflicts between membership on the advisory board a~d\\;'M~~pers'onal 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 Cily Council about the allocation of City funds, please list any present affiliations you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency,Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract A copy of Section 362,5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030, '" ~ ~ :?O <- .P=J > , -- -11 r) -< ~c... .=:2 s:: ..,.. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ~Yes 0 ~~ ~ s/, - DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR OMMISSION~D Yjij[lj.No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the sametime,) ,-,- , , r< '-.J 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 November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ j !~~~'t~ -..;;;...-...., ......,....- CiTY OF IOWA CiTY Name of City \j . . . Board/Commission ljn1Ath dJilsrH~ Cum(\'lj \.\iDYI Name <[ \\J~Q H'ob\'Ui Llrf\(lS Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). Date 1/3/ DC, List all businesses in which you or your spouse/domestic partner, ~a~efif applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or m f corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME If BUSINESS ADDRESS Y" SnJ./(t = 0"' ZQ L- :P> ) "",,",- - ~" , ~ :::;(; - [T -1J ..-, ::!l: Or:. - )> '" NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional busines~ 1. L Applicant Signature J , Signature of parent/guardi! n if Age 15 to 17: f Address Z. 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 November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION . APPLICATION FORM I ~ I ~~:._~..... !:~W;!:'"!. ,",," _lID" .......:. CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as utlpaid 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 NAME TERM: Age 15 to 17 (or) c:il:f.ge 1~ 21 :;Eo L- )>-1 ~ Il x.'::: -- r-- Youth Advisory Commission, Age on the date of filing: Signature of parent/guardian if Age 15 to 17: HOME ADDRESS \\O\0C\'{,"")( C".)+ Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 7 lr ~) . , r1P/~ .CCL;gu..-nCll7. · .-Q GU'A N l/..J\\\'-\uik; Lee rVenln, -EMP YER C('f$~ , PHONE NUMBER: HOME 31 q.;)')'j<, ''-1,710 BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR "PHIS POSITION: 'lAME Nl kk("d I*'nr\(:(-scw) , , .:--<r- rn <:l o::rJ :::l: ~/::: .z:- ~ lS7~UO lXJ Yes D No iT! :--t '--.) 'T~enQ.c~,"" [l'\if.- In cun/Yl!(''''l''tv} r c :pon5I'J)1~. -le.e, ;C\/}C /' "I ,,',.,' j'" " -j. .10....0',,' ,~ .' v'J, t}CLV(, vJiCUIij- {I/I,qro . J: /iC~UG (iJCU13 Id"'<'d.5 on l(}/la1 (zd<-,cJ-ls (UICi (JOU:ih C,(4Ivl+lf~.1 :r,(l1 -1r-..l~J au\ Ou -+ oqzi I'-\.\' i'O c6C i CL I Oil j . 'J [l... (L CJC()cI k{c0*-.f~ Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? ihcd ~rh'iS COra,cp i\':, O-,bC();j LjCA~1 13 o.clc~l-t'S ~fhCG-t (cxU1i '-{hI}):]S .fhoJ CLxE' hC)i :f),"E-SLVlied ;;1 -/IllS. COiJl/JiiJLi )ilLAta (-hcuxjiZ? I.. , CJ- '; (or rI)~~ {{\fA!1 IJl:'-t{C.%' WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? T>C5! 'hu-0 __ CUII~vl bldlt) JS) I~Le ~ bell iq Cc fteno:rrr r -Io...J I<v 70 rnlJ.-frj-etlcls ol::xJctt ,fC2:(c"t +'vlrIlW' flncd G-Xf_ n I IS':,. \1- ~ {. ' \ (\ _ 'r_q ,['T) '-!h.-t (OIO/)IILA,){fcJ"~lf- ,,-nc tLv-J-- 1V I-E:nds fl{A.\J( O--l6-t of-' ic\eCl'S 0\, whC\-\ \Qe eCUI do J tLA::\ cod-l c\() v)FrOLi <:J!, -i-j.-L(( tlc+ Cl\\04 \o..b\C, '. _ '. . , -t ' ., -IP'n~ ~"'d' (ptll OlUf', (!.i0hCILLS1 -Reej-po.cr',-- --i-(Y) 0-. gooo ({SI~IGr L~., J -to (.<..-<'1 tJ OY..Le"o +-t D '7) 'j di f/-q) 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. . 1 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 ermployee of the agency. Other types of affiliations must be examined on a case by case basis by the City Attorn$Y's office. You should also know that 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 of Section 362.5 is attached (see page 6). ...., If you are uncertain whether a potential conflict of interest exists or have questions aBout S@lion 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. ~Q, i;; ,-..-< -!J < - I =1 c) +- :- :< r- m r"1 -0 ,I 0:0 :x U <^ .r- IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? :KJ Yes DNo t;; . DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? DYes ltINO (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 November 2005 Page 2 of7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ 1 --= -lI:'l.., ~~~~'"t. -.;;:;.... ......., ...,..~ CITY OF IOWA CITY Name of City ,: 1\ 11'\ ' Board/Commission -1 in ~'t II +'<l1 \J i SDrLj (iNNYjI35/0() Name 'u, \c\xp0 W(Y~(>r'::~(rl Date Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINElSS ADDRESS 1\.) 0 I\J t, \JoNE - !::::> Sr-- = "" J>--] ~ - S2 : I '.' .c<r i-r-, R;Q ::&: ri ~. .r:- .. ...- c.n NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature 1'..\\\6 t e c\ \,\-cXy\p(~, ?'1ii Signature of parent/guardian if Age 15 to 17:lJ. /:/0.. , . 1/1~~ Address \ \n\~ r\r-F<;ctYI--\ 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 November 2005 Page 3 of7 (cont.) 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: 0 Females: 0 Council Announcement Date: November 15, 2005 Application Deadline: Wednesday, 5:00 p.m., January 4, 2006 Council Appointment Date: January 23, 2006 ... Said age requirements may be waived by the Council due to a Jack 0' applicants. YOUTH ADVISORY COMMISSION Two Year Terms - Aoe 18 to 21 January 1, 2006 - December 31,2007 Two (2) persons - Age 18 to 21 on the date of filing Maison Bleam lID 100 Rienow Hall Rm #941 Emily Truslow lID 420 N Dubuque St Michael Nelson 149 S Scott Blvd lID Eric Boucher lID 100 Mayflower Hall 201 B One Year Term - Aoe 18 to 21 January 1,2006 - December 31, 2006 One (1 ) person - Age 18 to 21 on the date of filing Jacqueline Stubbers lID 632 S Van Buren #4 Emily Truslow lID 420 N Dubuque St Eric Boucher lID 100 Mayflower Hall 201 B [RI Denotes applicant completed the Confidential page of the application. CITY OF IOWA CITY ADVISORY BOARD/COMMISSION J\,PPLICATION FORM I ~ I ::::~-_at... ~~~;!!:~ "-:' ...l1li.' .... .. CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 NAME Youth Advisorv Commission TERM: Two 121 years Youth Advisory Commission, Age on the date of filing: 0 Age 15 to 17 (or) III Age 18 to 21 Signature of parent/guardian if Age 15 to 17: N/* NAME Maison B. Bleam ....., o ~ jg5~-1119 ~() II Is your home address (listed above) within the corporate limits of Iowa City? III Ye&J cJ....J~o j- ..~ r-- ','I' How long have you been a resident of Iowa City? Five [5] months r-n ~ ri .Q =:2 :':.. \.J OCCUPATION Student-Universitvoflowa EMPLOYER ~~. ':': PHONE NUMBER: HOME Cell Number: [712].. 830 - 5082 BUSINESS rift. 1.0 EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: .JME ADDRESS 100 Rienow Hall Rm. #941 Student Body President.. High School Student Council : Hall President - Hall Gov. of Rienow & Quad Res. Halls Non..Voting Student Rep. .. MNW School Board Member - University of IA Parking & Trans. Charter Comm. Chair of Community Development - FFA : Member - Dean's Student Advisory Comm. [College of Liberal Arts & Sci.J Sen. Maj. Leader.. Lead America Congressional Forum [Washington D.C.] Sen. Maj. Leader - American Legion Boys State [VFW] Member.. UISG Committees. Page to the Chief Clerk.. Iowa House of Reps. 81st Gen. Assembly .Govemmental Relations Magistrate.. Student Traffic Court [UISG Judicial Branch] .Public Relations At-Large Senator.. UISG Undergraduate Activities Senate .SABAC .. Alternate Misrepresentations on this application will constitute just cause for removal of lin appointee. If you fail to answer all the questions, Council may not consider your application. venera I Application November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? My present knowledge of this board is that the Iowa City Council has assembled a group of youth to help in giving valuable perspectives, and insight, to the City Government on issues effecting youth. Hqpefully this Commission/ I'loard will succeed in its mission to "bridge the gap" between adults and young people ~y enabling youth to build Jadership skills, communicate ideas & concerns, and help in the decision making process effecting this age group. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVI~ORY BOARD (OR STATE REASON FOR APPLYING)? I feel, due to my background in various leadership positions, that I can provide helpful insight, perspectives, and analysis on arising issues. I have seen first hand - working in the state legislature - how laws and decisions are made. . I feel this would be a great learning experience to watch, and help make, important deci~ions affecting our great community we live in. Although Iowa City is great, there is always room for improvemenj. I have always been a huge supporter of youth to take on leadership roles and participate in the decision making process. I am proud to be apart of a community that believes youth opinions are so important as to form a commission/board that specifically represents and promotes their views. I sincerely hope that I am selected to serve on this unique, historic, one-of-a-kind, coml1)ission/board. 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 iyou 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 AttomlllY's office. You should also know that Section 362.5 of the Code oflowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A co~ofSecfi!}n 362.5 is attached (see page 6). .~ 0 ~ >--; rri If you are uncertain whether a potenti~1 conflict of interest exists or have questions ab~t::Secttyh 3W of theCode of Iowa, please contact the City Attorney's office at 356-5030. ~ C U1 c..... N/A 11i O::rJ ;E^ )> -0 I I 3: 0 'I! \D IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? IZI Yes D No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMI$SION? DYes IZI No (It has been Council policy not to permit an individual to serve on two Boards or Cornmi~ions at the same time.) Misrepresentations on this application will constitute just cause for removal o~ an appointee. If you fail to answer all the questions, Council may not consider your application. -.;eneral Application November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ 1 =--....14'... f~~;!!!:'"!. "".. -.., .......~ (ITY OF IOWA CITY Name of City Board/Commission Youth Advisory Commission Date ..@Q.~2005 Name Maison B. Bleam Section 362.5 of the Code of Iowa generally prohibits, with certain important exc~ptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corportation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINE$S ADDRESS N/A N/\6. ....., . ~~ = en . P-j ~ ~ o ' I '.1 --<r i-n r=:;':D ::!: n ~" ~ :::: NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional bus~'ness. Applicant Signature . ."4.- Signature of parent/guardian if A e 15 to 17: tJ/Pr I Address 100 Rienow Hall Rm. #941 Misrepresentations on this application will constitute just cause for removal o~ an appointee. If you fail to answer all the questions, Council may not consider your application. veneral Application November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION \PPLlCATION FORM I ~ I --= -14.., f~W~'"t. -..::..... ......., .........~ CiTY OF IOWA CiTY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. This form may be filled out manually (please use a black ink pen), typewritten, or electronically (PDF). Retum the application to City Clerk, 410 E. Washington St., Iowa City, Iowa. THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUC~D 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 NAME Youth Advisory Commission TERM: 2007 Youth Advisory Commission, Age on the date offiling:D Age 15 to 17 (or) ~ Age 18 to 21 Signature of parenUguardian if Age 15 to 17: . ,OME ADDRESS 149 S. Scott Blvd. ...., (5 !5 ..- c.n )>~ ~ .--,_< n '.0 I --I C) 0\ -../'C-'.- ilE [522450 '.:> Xi :1 o Yes~ TI fIo )> N 11 ! in U NAME Michael L. Nelson Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 1 1/2 Years OCCUPATION Student EMPLOYER None - Student at U of I PHONE NUMBER: HOME 5636506926 BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR HilS POSITION: I was a two-year member of Teens for Tomorrow, a committee of high school students that delegated $5000 a year to charities in the Quad Cities area. As a board member I received and reviewed grant applications, conducted on-site visits of the non-profit organizations, and voted to determine which applications would be granted. This gave me a wide range of hands-on experience with non-profits, ranging from the Putnam Museum to the Valley Shelter house for youth to Quad Citians Affirming Diversity, a support group for bisexual, gay, lesbian, and transgender youth. I was also a two-year editor of the "Spartan Shield", Pleasant Valley high school's student newspaper. As a reporter I gained experience in the city government, having conducted interviews of the city attorney and police chief Misrepresentations on this application will constitute just cause for removal o~ an appointee. If you fail to answer all the questions, Council may not consider your application. . ",eneral Application November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I understand that this is a new committee that will work with a liaison to the Council to provide a perspective on issues that affect Iowa City youth, WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? I feel I can offer my experience and perspective to better serve the city of Iowa City as a' whole by providing a perspective on youth, By engaging young citizens in the civic process, we better create a democratic environment that benefits everyone, I am applying for this position to gain experience in the local government at a pivotal point in my life, As a sophomore in college, I am trying to explore opportunities that will help me determine what I will do with the rest of my life, POTENTIAL CONFLICTS OF INTEREST Please identify any potential conflicts between membership on the advisory 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 m~kes reCommendations tothe ,ty Council about the allocation of City funds, please list any present affiliations iYou 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 Attom~y's office, You should also know that Section 362,5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract, A copy of Section 362,5 is attached (see page 6), r-> 0 = = <J1 ~O <:::> )>~ fT1 -n -" n () I -ie:' en , ,-<, -0 hl [T, 0 ~^ .r:- boarJ>and N Y9l:lr personal 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, I~" IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 0 Yes D No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMI$SION? DYes 0 No (It has been Council policy not to permit an individual to serve on two Boards or Commi~sions at the same time,) Misrepresentations on this application will constitute just cause for removal o~ an appointee, If you fail to answer all the questions, Council may not consider your application, General Application November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES: BUSINESS LISTING I ~ I =:::....;;14'... :f~w;!:'"I. ~ ....,~ .....~ CITY OF IOWA CITY Name of City Board/Commission Youth Advisory Commission Date 12/01'/2005 Name Michael L. Nelson Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Sectio~ 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if apJ)licant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. . BUSINESS NAME BUSINESS ADDRESS None 0 = = . ~O S? n-< " Tl -iC; CTI I .CD -0 L!..' ~7 .:::- \..J )> N ''\J NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an addition,al b~isin~~~1 ( ;i Applicant Signature . /" ,( X /~ _. Signature of parenUguardian if Age 15 to 17: Address 149 S. Scott Blvd. 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 November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION AI1PLlCATION FORM I ~ 1 ~~S__ItI... ~~~W;!:~ -.,;;;:,.... ~..,~ ..,..... CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 "CONFIO-=NTIAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. ADVISORY BOARD/COMMISSION NAME Youth Advisory Commission Youth Advisory Commission, Age on the date of filing: 0 Age 15 to 17 (or) TERM: 1 vear N. 'E Jacqueline Diane Stubbers [l] Age 18 to 21 - "" o g ~() ~ ~ f"'T1 _ ()-<... I ~ --1() Q) i ,-< h:; " m ~2~ 0 )> .. llIYes [fNo Signature of parent/guardian if Age 15 to 17: HOME ADDRESS 632 S. Van Buren #4 Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 2 years OCCUPATION Student EMPLOYER Univ~rsity of Iowa PHONE NUMBER: HOME (515)554-7745 BUSINESS EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR tHIS POSITION: During high school, I was a part of the debate team which gave me some insight to the workings of the govemment and how they cooperate with communities. Also, I have been a part of the Sponsorsh~p Committee for Dance Marathon at the University of Iowa for a year now, and this position has shown me the importance of getting involved with the community and developing leadership skills. From 1998-2000, I was! a part of a youth advisory board for United Way in the Des Moines area. Our committee created a program whidh helped shuttle the area's youth from school to various locations that provided safe, productive recreation. '~isrepresentations on this application will constitute just cause for removal ,of an appointee. If you fail ,0 answer all the questions, Council may not consider your application. General Application WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? This board was just brought to my attention by a newspaper article in the Daily Iowan. After reading the article, I went to the commission's website and read about the mission of the board. WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVlpORY BOARD (OR STATE REASON FOR APPLYING)? I decided to apply for this position because I believe that it would be a good way for mE! to get more involved with the Iowa City community. I believe that I would be able to lend my leadership and dedication to this board. As a fairly new inhabitant of Iowa City, I know very little about the govemment here and it's activities, so I would definately be able to provide an unbiased opinion on various topics that would come up for discussion. I believe this board would be a great opportunity for me to leam more about the city I live in and what goes on hare. o g $"" en l.~ , I"T1 POTENTIAL CONFLICTS OF INTEREST Q =< ';' 21 Please identity any potential conflicts between membership on the advisoiY boa:PanJDyo~r, rersonal interests, including financial interests and your duties to an employer. 0 S3 ~ 0 -A - In , .Articular, if you are applying to be a member of a board or commission which r\'lakeiiecom~ndations tothe City Council about the allocation of City funds, please list any present affiliations you have 'NIth 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 Attortney's office. You should also know that Section 362.5 of the Code oflowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contrlict. A copy of Section 362.5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions 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? III Yes 0 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 0 Yes III No (It has been Council policy not to permit an individual to serve on two Boards or ComllTlissions at the same time.) "vlisrepresentations on this application will constitute just cause for removal of an appointee. If you fail (0 answer all the questions, Council may not consider your application. General Application BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ I ~~~~'t -..:::.... ~...~ ...... .. CITY OF IOWA CITY Name of City Board/Commission Youth Advisory Commission Date gq1/2005 Name Jacqueline Diane Stubbers Section 362.5 of the Code of Iowa generally prohibits, with certain important exqeptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Sectilbn 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if aAplicant is Age 15 to 17. have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINl:SS ADDRESS WoNG: 0 <=> = $Q ;;;:> C)-< c-J 11 ~c co 1- , , ;=:;gj ~ !-.0 ~~ ~ 'o.......J ~ NOTE: A new form must be completed if the above information changes or' an ownership interestis acquired in an additional business. Applicant Signature ~~ lJ. ~fLV Signature of parent/guardian if Age 15 to 17: Address 632 S. Van Buren #4 Iowa <:'1'fJ. rII 5mD 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 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION . .PPLlCATION FORM I ~ 1 ;t~~~'t '--~ "aD,' ---- .. CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 "CONFIOIINTIAL." THIS APPLICATION WILL BECONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONsilDERED FOR ANY VACANCY DURING THAT TIME. ADVISORY BOARD/COMMISSION NAME Yo III h ~A Ii, ,,;orlj (c tnffiL 5S1;Of) TERM: Youth Advisory Commission, Age on the date of filing: 0 Age 15 to 17 (Or) [SJ Age 18 ~ 21 - = o ~ Signature of parent/guardian if Age 15 to 17: -:;;: (") r""l )> -' ':?1 ..,., \ME -F m 1lj Dex\ \ c..e Trll <d ouJ HOME ADDRESS Y20 I\l [)\Ll,\lOlllll TOIJJel C t~ I IA Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? _I '17 ~ P. 0 r <; OCCUPATION ph 0"0 .Le.u..m rNJ m bc...... EMPLOYER PHONE NUMBER: HOME '117-' Z 60 . Z L.J I CJ BUSINESS - EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR lHIS POSITION: M~ lu:~ rQn5C ot expe.1cenaLS o..nd o..c.-hv,l\es 9lVe.s mQ. Q broo..cl o.ncL ~\VUS\t\~cL Vl-t:.WpOLf\t fcorY' wl\lc..h rn~ OpLn\0ns Qncl SU33(!stlons CLre rvrm.ed .1. r.o..\Jt voll..\Y1. 'h.ued Qt mClYty l6GClt\..0r'1,s u,Clu.d\i'3: (Ln eLttn.f.htOJ'-j sc.hooL, o...r\\()"\C1'\' s\-wllu-1 Qnd. h01~~SS shLl-le.-r T\Y1 Q me.rn bey- 0+ tKe.. AmeTLCD.h Mo.-r'\?ehns )\SSOUCltLc..n cI..nd Wovr1.i'.n In BU.:SlN.SS. ALso; I helVe.. Sornz Rnowl..ecLqQ. 0+ q00ernYY\Q.n1. proc.e.clu..re.s becCLU.S<I. .-L hcld tiLlL POSLtc ()" d: \/l d pr€51'cknt on rYly h'gh sc.noeL 5tuclt.n.t c0u.n(xL. 0--"" I -,-..... co ! --1,) m .:.-< ;--- -0 t! _fT1 ::E: U . zl~~2~-.S lliJ Yes }> 0 NQll LLI')LVe.rsd:.~ of Iowo... 0:('+, CD at Arl""u;,ons 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 November 2005 Page 1 of 7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Ih.~ ,-\c'-'.U, <u:lvC') ory Cem mL S3L()n \}J~Ll co!'\ 5 l3 t of Se.vU'l Ine.m be.rs ~3e.. If) _-to 2-\ l0r.Oc.0,liiU;Ltht~ h.~Lp ot CL GetLl (ow,c,l LLo.lSOiJ, (r\Q~ :5l\.'j<)-tsboY'.s O-ncl provccl..L lnpQt on l::'~UL.S p~rtvucnl 1::0 l:h.rLlf' ::>e..ers, WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? J.. WOu~cl ClpP'HlClle- 1:~ oppOrhLrhtLjb SMve.on U'ILS boecrd. Ive.C(l\.ls.e. I C-Qx, pCC!Vlc:k. t~ c,bj vtCJl..LnuL w~ lh Hu- :Jou.n.Cj o.duLt \f dcwpCJvnt. thL.:) axe 5Ce..~ ((13i CUI~ 6ecccuse. ~ pLG<.n on L'V.'hq Ire .lowQ lltl.j for Q \'I\L()lm\A."", o-\- tw()rn(jr~ ~e.uls, j.. wouLd LL~ to hQ\J e. . Cl \i OL ClLl0 ~t~J'vY\ [nulj Corn rnu.J\Lt PCLLC,-\ -th~t WLLl o..+te..ct ~.t. OJlcl, those.. OJou..nc1 ~jAlso.l U'U.. Rnow'leclge. .1- woc.cLd 3CLln from HilS eXF.~,h-en~ wouLd Qld. \'Y\Q. Ln lYl:::J LL L bmo.te 30 Gl L ot l CU.-LJ .:s ch ooL . 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 mflkes recommendations tothe City Council about the allocation of City funds, please list any present affiliation$ you have with agenciesthat apply for funding from the City. "Affiliation" includes being a board member or employee of the agency.Other types of affiliations must be examined on a case by case basis by the City Attorney's office. You should also know that Section 362.50fthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract A copy of Section 362,5 is attached (see page 6). If you are uncertain whether a potential conflict of interest exists or have questions about Section 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. 0 g ~O ~ o~ ';' 11 =jG co r ':--...1 m m .." :~ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? D Yes [2]~;:::- '-J DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION1 D 'AnI [ZI 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 af an appointee, If you fail to answer all the questions, Council may not consider your application, General Application November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ 1 !~~~'t "i;;... "IIIII~ ...,.. .. CITY OF IOWA CITY Name of City Board/Commission 'lout.\' A (rL, "CI{~ COmrn I '\5l0h Date 12-4.. 65 Name ~ \'n \ \ J O{l,h I S p-Tru ," LouJ Section 362.5 of the Code of Iowa generally prohibits, with certain important exoeptions, a memberof a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS rlM"D ;:=:; = = zO ~ .>':< C'"1 '-! . '~O co \-on ~\T: ::l! h q~ - ):> - NOTE: A new form must be completed if the above information changes or an ownership interestis acquired in an additional business. Applicant Signature ~Q /h./-bL ([n /1 ^~ U Signature of parenuguard~ 17: Address In,,U N. OI.lI,ll q'- [1) I ow a (, L'j J T A ~ 22 Lj j 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 November 2005 Page 3 of 7 CITY OF IOWA CITY ADVISORY BOARD/COMMISSION ~PPLlCATION FORM I ~ 1 -,...: -14>... :f~W;t:~ -...:;:... ......'- ........ .. CITY OF IOWA CITY Individuals serving on Boards/Commissions play an important role in advising the Council on matters of interest to our community and its future. Applicants must reside in Iowa City. After a vacancy has been announced, the Council reviews all applications during the work session. The appointment is made at the next formal Council meeting. Appointees serve as unpaid volunteers. 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 NAME Yovt'h TERM: ZOOb Youth Advisory Commission, Age on the date offiling:D Age 15 to 17 (or) ~ Age 18 to 21 Signature of parent/guardian if Age 15 to 17: NAME frlc.. ~ . ;-lOME ADDRESS J Of) ff\a.yfliwer JJJI ZiJI P Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? 5 ~~.s OCCUPATION ---.Stvdt/rr EMPLOYER ~~~; 1''1 uF :Iu~ PHONE NUMBER: HOME 402. ~2../S-qhJO BUSINESS ZIP 522..42- IE1 Yes D No EXPERIENCE AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: PlDt Protvl fvrtJ..fc.U~N' Or~-I~~ V fAi\ i ty S o(lj!Jl' ~ r-A,I\ It'lJ~ S o(..vetf rum fhAAfA..Jtq' A~";c. OeaukaJPIl Cofhti 1\ Nc.ttiO'f\Cc,\ merit 5cho)o.r 0 '" = = ~o cro <- >= ~, -1 :;e I] CJ-:: I ---lG .s:- ,- f ~-<r iTf m .." 0::0 ::x r-. V -s;:......... .r:- :;;, 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 November 2005 Page 1 of7 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Th~ YDV'fh Akl.sot'7 8oCV-& rep~f!/vrs ~ c,.Pllc.RI'AJ of y()lJllJ ~/f-r i~ :r.CP'0- Cit, q-() -tlte. city J.ir{J(,t~~ WHAT CONTRIBUTIONS DO YOU FEEL YOU CAN MAKE TO THIS ADVISORY BOARD (OR STATE REASON FOR APPLYING)? 1 u.aJ0. be. tJ... lK&./lJc1bk /'(\€/(\bet' -tk ~ wild be~.I ~"eHAt' tk ryfCo.l Ullivoo;ty 0 .I0\Ll9.. srv~t. J: tM~.xA&. ~rerfAt ~ W/llbfb if- .!T1IJ#,.~ ~c? ore. /lot" .IoU(). Q~ (lO.tivf5 but" '-tJ.l( j r hQ~ /01' q Mo.1ms of. the. YeoY'. .:r: G\hI M'rBttly () tteJhmOl\ (ANi :r.. IInder..s f1(JI& 11vt fV'OUfMS oM v:.tts tlO1s (lW ~ttlM15 have. ~ f~ey ~ tt> the. city 'Ir,,, ..,k Ars t- ti~e. Ovw I-n..IA k 1k'1 pfA ;fiC>.1 ()..j /10. tyfit4.1 slvdc..1" Wov /&. I'tse.1, r a.14lfJe. pOi"t" df- tH. yOJl\j' aJv/r C/)M/'tl(/nit. 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 know that Section 362.5 ofthe Code of Iowa generally prohibits, with certain importantexceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 6). ..., - = If you are uncertain whether a potential conflict of interest exists or have questions a~'6seeffon 362.5 of theCode of Iowa, please contact the City Attorney's office at 356-5030. )> =; ~ 0' I ~o .- -"" ,..---' "_" I n-: -u -~~ ::J: O~~ <:.:,,- .r;::- !vA I m u ~ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? KI Yes No U1 DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 0 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 November 2005 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I ~ I ;t~~~'t -..:::...._....~ ..,..~ CITY OF IOWA CITY Name of City ttj \ Board/Commission )()Jl(~ Name .. tric. f>ova&" Date /2 ~Zq-05 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a memberof a city Board or Commission from having an interest in a city contract A copy of Section 362.5 isattached (see page 6). List all businesses in which you or your spouse/domestic partner, or parent if applicant is Age 15 to 17, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation'sstockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS A./II 1'1 n "" ~ = .... ::i>~ i;; 0-" I IJ -j" ...- L. .:-<r- .1." ~ r--; "":D ~,'" .r- " . .... -:: 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 parenUguardian if Age 15 to 17: Address 100 (haltP/()JJff JJr,11 WI/J SOl,Ud- ~'i] : 1 A S22.W1. 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 November 2005 Page 3 of 7