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HomeMy WebLinkAbout2012-07-31 Appointments17a NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: AD HOC DIVERSITY COMMITTEE Seven Vacancies — Six -month Terms September 1, 2012 — March 10, 2013 The duties of the Commission are: 1) to study the operation of the City's transit system, including but not limited to the downtown interchange, as it relates to minority populations with a view toward promoting just and harmonious interaction between City government and minority segments of the community; 2) to study the operations of the City law enforcement, including but not limited to the Police Citizen Review Board (PCRB), as it relates to minority populations with a view toward promoting just and harmonious interaction between City government and minority segments of the community. The Diversity Committee shall submit a written report to the City Council by March 10, 2013, that responds to each of the charges listed above and that contains recommendations, if any, with respect to each of the charges. Absent further action by the City Council, the Diversity Committee will dissolve on March 10, 2013. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Ad Hoc Diversity Committee shall determine the frequency and conduct of its meetings. Meetings will be held at City Hall, 410 E. Washington Street. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. 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 Ad Hoc Diversity Committee 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 Council Announcement Date: June 19, 2012 Females: 0 Application Deadline: Wednesday, 5:00p.m., July 25, 2012 Council Appointment Date: July 31, 2012 AD HOC DIVERSITY COMMITTEE Seven vacancies — 6 -month Terms September 1, 2012 — March 10, 2013 (M) Joe Dan Coulter 0 1818 N Dubuque St (M) Orville Townsend, Sr 0 (Human Rights Commission) 713 Whiting Ave (M) Jerry Bokassa rx-1 Forest View Trl Ct PO Box 1905 (M) Kingsley Botchway 0 (Police Citizens Review Board) 260 Scott Ct, Apt 3 (F) Donna Henry M 1926 Broadway St i (M) Rod Sullivan 0 2326 E Court St (M) Charles Eastham 0 (Planning & Zoning Commission) 37 Colwyn Ct (M) Bakhit Bakhit 0 2610 Bartelt Rd, Apt #10 (F) Royceann Porter 0 (Police Citizens Review Board) 136 Appanoose Ct (F) LaTasha Massey 0 2315 Friendship St (M) Donald King El (Police Citizens Review Board) 2374 Kristian St (F) Joan Vanden Berg rx-1 309 Fairview Ave (F) Cindy Roberts 0 2034 Grantwood St (F) Mary (Polly) Nichols- Marshall 0 621 Brown St El Denotes applicant completed the Confidential page of the application. City of Iowa City r 1 Advisory Board /Commission /Committee; "' . � ,:)plication Form -^�-�- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY C SIDE D O !jN V CANCY DURING THAT TIME. Advisory Board /Commission /Committee Name V(% u / � er %�� "1 Term DG� Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Z70✓ U/6 -/4 HOME ADDRESS /9 / ?x Aa rJu9?,41-,5,t_ - �r Is your home address (listed above) within the corporate limits of Iowa City? Yes F] No How long have you been a resident of Iowa City? Xloelef- Gender: Male R'FemaleF] OCCUPATION EMPLOYER VrfC�r�} PHONE NUMBER: HOME BUSINESS 44 del, 9/-, , 1'�l�`� r.' EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU .FOR THIS POSITION:' WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? G WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR4PPLYING)? /�.fS�lSf �j�/L'P. 2�c6yh !r►vk �.9�r� S �!� VUOivG� r i v�.�' � �,- Jjnn n.c� /.0 1.511--e IN-1/1CIP-PLe 0-71 MAJVPe1V t�_ 4-n V�. /� �-4TeJ/� %✓��J� �1s� �� LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Intermt /yd�l�o se e,, dhile Q ��.�I r/ •� �a�-rs o-ru J IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? PYes F� No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes [--]No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail io answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2 of 9 � r i BOARD, COMMISSION, & COMMITTEES - •�.,�_ BUSINESS LISTING CITY OF IOWA CITY Name of City �t Board /Commission /Committee Date Name %-�6>F ,94AI Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in a12 additional busi ss. Signature �� lk Address M II Misrepresentations on this application will constitute just cause for removal of an appointee. II .f you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) nPTInNAI PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. Age ,6�6 7 Gender o�i -t- Income (see table) WIler i Sexual Orientation F-10ther (Please explain below) / ' -"/A.1-0, Disability r *4/l!i _ 'Race, color or ethnic group 14y/J` National origin - G3 Human Rights Commission Application - r January 2012 page 4 of 9 `' BIOGRAPHICAL SKETCH Cl Provide the following information for the key personnel and other significant contributors in the order listed %Form Pagp2. Follow this format for each person. DO NOT EXCEED FOUR PAGES. NAME POSITION TITLE Joe Dan Coulter Professor eRA COMMONS USER NAME icoulter y EDUCATION /TRAINING (Begin with baccalaureate or other initial professional education, such as-nursing, and include postdoctoral trainin . ) `*; INSTITUTION AND LOCATION DEGREE YEAR(S) FIELD OF.STUDY (if applicable) University of Oklahoma, Norman B. A. 1966 Psychology University of Oklahoma Medical. Center. Oklahoma City Ph.D. 1971 Biological Psychology University of Texas Medical Branch, Galveston Post -doc 1971 Neurophysiology Universita di Pisa, Pisa, Italia Post -doc 1973 Neurophysiology University of Edinburgh, Edinburgh, Scotland Post -doc 1974 Neurophysiology A. Personal Statement Dr. Coulter is an enrolled member of the Citizen Potawatomi Nation of Oklahoma (federally recognized) and is active in the American Indian Science and Engineering Society, National Indian Education Association, National Institute for Native Leadership in Higher Education, the American Indian and Alaskan Native Professors, the Society for Chicanos and Native Americans in Science, the Native Research Network, the American Indian, Alaskan Native, Native Hawaiian Caucus of the American Public Health Association and the American Indian Higher Education Consortium (tribal colleges). Dr. Coulter is also a member of the External Advisory Committee of the Montana State University (MSU) Idea Networks for Biomedical Research Excellence program, an NIH funded program to improve biomedical infrastructure for Montana's higher education system, and 7 tribal colleges. For MSU, he also serves on the External Advisory Committees of the NIH supported American Indians into Research Program, the Center for Native Health Partnerships supported by the NIH NCMHD and the NIH supported Culturally Connected Community Goals program. He is also a former member of the External Advisory Committee of the NIH RISE program, a collaboration between Haskell Indian Nations University and the University of Kansas. In 2008 he was appointed to the External Advisory Committee of the Northern Plains Tribal Epidemiology Center/Native Americans Research Centers for Health program of the Aberdeen Area (Great Plains) Tribal Chairman's Health Board. From 2004 to 2009, Dr. Coulter served on the Association of Schools of Public Health (ASPH) Diversity Committee, and is currently a member of the ASPH /RAMC Committee Expert Panel on Cultural Competence and the ASPH - Indian Health Service Taskforce. Dr. Coulter also serves as faculty advisor to American Indian and Alaskan Native students on campus and in 1989 helped establish and directed the Life Sciences Comprehensive Enrichment Program for pre - college American Indian /Alaskan Native students at The University of Iowa. In 1998, he assisted in the establishment of the Iowa First Nations program that provides resident tuition status for members of American Indian Tribes/Nations historically linked to the State of Iowa. Since joining the College of Public Health, Dr. Coulter teaches, conducts seminars, and makes public presentations /trainings on racial /ethnic health disparities and development of cultural competence, and organizing community -based participatory health programs, in particular regarding American Indians /Alaskan Native populations. He is also an advisor to the Historical Preservation Project of the Meskwaki Nation of Iowa, served on the Iowa Governor's Equal Employment Opportunities Task Force from 1997 -1999, and served two 4 year terms on the Iowa Advisory Committee of the United States Commission on Civil Rights. In 2008, Dr. Coulter was appointed by Iowa Governor Chet Culver to the Iowa Commission of Native American Affairs where he has been elected to serve as the Liaison to the Iowa Department of Public Health. In 2010, Dr. Coulter was again PHS 398/2590 (Rev. 06/09) Page / Biographical Sketch Format Page appointed to the Iowa Advisory Committee to the U.S. Commission on Civil Rights. In 2011, he was appointed to the Governance Board of the Regional Health Equity Council of the National Partnership for Action (NAP) to End Health Disparities of the U.S. Department of Health and Human Services, Office of Minority Affairs. B. Positions 1975 -78 Assistant Professor, Department of Physiology & Biophysics and Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch, Galveston, Texas 1975 -85 Member, Marine Biomedical Institute, Galveston, Texas 1978 -84 Associate Professor, Department of Physiology & Biophysics and Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch 1980 -81 Associate Program Director, Behavioral & Neural Sciences Division, National Science Foundation, Washington, D.C. 1983 -85 Assistant, Office of the Associate Dean for Community Affairs, University of Texas Medical Branch 1984 -85 Professor, Department of Physiology & Biophysics and Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch 1985 -92 Head, Department of Anatomy, College of Medicine, University of Iowa, Iowa City, Iowa 1988 -96 Chair, Neuroscience Graduate Program, Graduate College, University of Iowa 1996 -99 Interim Associate Provost for Diversity and Director, Opportunity at Iowa, Office of the Provost, University of Iowa 1999 -04 Associate Provost for Diversity and Director, Opportunity at Iowa, Office of the Provost, University of Iowa 1985- Professor, Department of Anatomy and Cell Biology, College of Medicine, University of Iowa 1985- Professor, Neuroscience Graduate Program, Graduate College, University of Iowa 1993 -04 Coordinator /Liaison, American Indians & Alaskan Natives. Opportunity at Iowa, Office of the Provost, University of Iowa 1994- Participating Faculty, American Indian and Native Studies Program, College of Liberal Arts and Sciences, University of Iowa —n 2004 -08 ;z-- Associate Dean for Diversity, College of Public Health, University -cif :Iowa 2004- Professor, Community and Behavioral Health, College of Public Health, Universof Iowa W u Honors (Selected)_ 1996- Association of American Medical Colleges Elected _C1tfcei /,Distingu -ished _ Service'Memb�' 1999 -04 Explorations in Biomedicine: Native American FacultyScientis't-) Issues In Science Education and Research, American Physiological Society, Montana State University 2001- Association of Neuroscience Departments and Elected Officer /Distinguished Programs Service Member Federal Review /Advisory Committees: (Selected since 2000 from a total of 25 since 1980) 1999 -2004 Member, Research Centers in Minority Institutions Review Committee, National Center for Research Resources, NIH 2001, 2002 Member, Special Emphasis Panel, Biomedical Research Infrastructure Network, National Center for Research Resources, NIH 2002 Member, Special Emphasis Panel, Centers of Biomedical Research Excellence, National Center for Research Resources, NIH 2002 -2004 Chair, Research Centers in Minority Institutions Review Committee, National Center PHS 398/2590 (Rev. 06/09) Page Biographical Sketch Format Page for Research Resources, NIH 2003, 2004 Chair, Special Emphasis Panel, Centers of Biomedical Research Excellence, National Center for Research Resources, NIH 2003 Member, Special Emphasis Panel, Pre- doctoral Awards for Minority Students and Students with Disabilities, NIH Center for Scientific Review 2004 Member, Committee of Visitors, evaluation of Tribal Colleges and Universities Program, National Science Foundation 2005 Member (Ad hoc) Research Centers in Minority Institutions Review Committee, National Center for Research Resources 2005 Member, Broadening Participation in Computing Review Panel, National Science Foundation 2006 Member, Special Emphasis Panel, Pre - doctoral Awards for Minority Students and Students with Disabilities, NIH Center for Scientific Review 2008 Member, Special Emphasis Panel, Clinical and Translational Science Awards, National Center for Research Resources, NIH 2008 Member, Research Centers in Minority Institutions and IDeA Review Committee, National Center for Research Resources, NIH 2009 Member, Community -Based Participatory Research, Panel 2, National Centers for Minority Health and Health Disparities, NIH 2012 Member, Healthcare Safety and Quality Improvement Research (HSQR) Study Section, Agency for Healthcare Research and Quality C. Selected-peer- reviewed publications from a total of 79 (in chronological order): Gwyn, D.G., Ritchie, T.C. and Coulter, J.D. 1985. The central distribution of vagal catecholaminergic neurons which project into the abdomen in the rat. Brain Res., 328:139 -144. Fabian, R.H. and Coulter, J.D. Transneuronal transport of lectins. 1985. Brain-Res., 344:41 -48. Ritchie, T.C., Fabian, R.H. and Coulter, J.D. 1985. Axonal transport of antibodies to subcellular and protein fractions of rat brain. Brain Res., 343:252 -261. Ritchie, T.C., Fabian, R.H., Choate, J.V.A. and Coulter, J.D. 1986. Axonal transport of monoclonal antibodies. J. Neurosci., 6:1177 -11 Ritchie, T.C., Thomas, M.A. and Coulter, J.D. 1989. A nerve terminal protein with a selective distribution in spinal cord and brain. J. Neurosci., 9:2697 -2709. Cabalka, L.M., Ritchie, T.C. and Coulter, J.D. 1990. Immunolocalization and quantitation of a novel nerve terminal protein in spinal cord development. J. Comp. Neurol., 295:83 -91 Wright, D.J., Ritchie, T.C. and Coulter, J.D. 1991. Distribution and developmeripi expression _of the nerve terminal protein NT75 in rat cerebellum. J. Comp. Neurol., 304:530 =545` Kanekar, S. S., Ritchie, T. C. and Coulter, J. D. 1993 Spinal cord afferent systerns-6od ining'tft nerve terminal protein NT75. J Comp. Neurol., 332:198 -212. Selected Invited Talks/Presentations from a total of 51 (since 1997):1 Making a Difference: Culture, Science and Community. Banquet Presentation. CMS National; al­, Minority Research Symposium, New Orleans, Louisiana. October, 1997: =� Achieving Racial /Ethnic Diversity in Biomedical /Behavioral /Social Science Research. Panel 1. Progress in Recruiting, Retaining, and Graduating Underrepresented Minorities on Regular NRSA Institutional Training Grants. Panel 2. Panelist and Presenter. National Institute of Mental Health Workshop on Minority Training Programs. Washington, D. C., October 1999. Inextricable Links: The Convergence of Diversity and Academics in Higher Education. Panel Presenter. The College Board Midwestern Regional Meeting, Chicago, Illinois, September, 2001 Community-Based Participatory Research with Tribal Communities. Featured Presentation. Montana INBRE Research Conference, Red Lodge, Montana. September 2005. Healthy Smiles Study: Community-Based Participatory Research on Oral Health of Northern Plains Indian Children Presentation, Blackfeet Community College, Browning, Montana, July, 2008 PHS 398/2590 (Rev. 06/09) Page A Biographical Sketch Format Page D. Research Support Onzoing Research Support RFA -MD -05 -004 (Lefthand) 10/01/08 - 09/30/12 NIH/NCMHD Building Research Infrastructure for the Crow Community (BRICC). The NIH Research Infrastructure in Minority Institutions (RIMI) program at Little Big Horn College builds on the campus commitment to the professional, vocational and personal development of Crow Indian students in both higher education and the workplace in the health sciences and research. Role: Principal Investigator on sub - award /Consultant for evaluation. Completed Research Support (since 2004) Cooperative Agreement 1 U48DPOO1 902 -01 (Nothwehr /Parker) 03/01/11-02/28/12 CDC/National Center for Chronic Disease Prevention and Health Promotion University of Iowa Prevention Research Center for Rural Health. The focus of the PRC -RH is to improve the health of rural communities in Iowa and the Midwest through participatory research. The research themes are nutrition, physical activity, and aging. These are strongly in line with the health priorities identified by state and local entities. The PRC -RH uses a logic model which describes the activities and related outcomes of the PRC -RH consistent with the national CDC Prevention Research Center Program logic model. Role: Co- Investigator. 1 R24 MD001658 -01 (Robertson/Jaiyeola) 9/30/2005- 6/30/2010 NIH/NCMHD Using CBPR to Improve Oral Health in Northern Plains Indian Children. The overall objective is to plan and develop appropriate interventions to improve oral health in Northern Plains (South Dakota) Indian Children using a community based participatory research (CBPR) approach. Role: Principal Investigator on sub - award. .. - --- —. U90/CCU724262 -01 (Atchison) 09/0'1/2004 = 68/311009 CDC `. ;... _ c <� Upper Midwest Center for Public Health Preparedness. - -: -� The Center's objective is training of the public health workforce, including tribaj:hes althl�ers6nne1 and emergency responders, to respond to bioterrorism and other public health emergencies ww Role: Co- Investigator for tribal preparedness (2004 - 2008). _ =' 1 R 13 HSO 16435 -01 (Osterberg) 06/01/2006-05/31/2007 Agency for Health Care Research and Quality Asthma Education Conference for Tribal Health Officers Serving the Aberdeen Area. The project conducted a regional conference on asthma designed to inform representatives of Northern Plains tribal health agencies about the current state of knowledge, research and treatment of asthma, its potential environmental triggers, prevention strategies, and environmental improvement measures. Role: Co- Investigator. RFA -RM -07 -002 (Hunninghake /Rosenthal) 09/01/2007-08/31/2010 NIH/NCRR University of Iowa Clinical and Translational Science Program. For the Community Engagement component, establishing working relations in clinical research in partnership with Federally Qualified Community Health Centers has been a priority, including developing qualifications for Federal Wide Assurances, training in human subjects' research, HIPPA, and. Institutional Review Boards approvals. Role: Co- Investigator for Community Engagement. PHS 398/2590 (Rev. 06/09) Page Biographical Sketch Format Page City of Iowa City _J r 1 Advisory Board /Commission /Committee �;r'� pplication Form - -�-� -- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name A C, h w D i u 2.2 s it LA Term Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME 0Y J'J ( tC, HOME ADDRESS 713 W hr'il nu A oe. Is your home address (listed above) within the corporate limits of Iowa City? Pq Yes No How long have you been a resident of Iowa City? SQ�J Pg , Gender: Male ® Female OCCUPATION Ic.e-1 1 R c-� EMPLOYER PHONE NUMBER: HOME EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL BUSINESS QUALIFY YOU FOR THIS POSITION: (Z h..Cto,� b-e•e n (!k- ri�Yn- 6erac.es �o� {�-�— C�inrrtr %{•e es S�t�Ce,z: l4lfiDZC.�.�ytn C"-t77 Co Gtn-L L �7, L �-i rrcce�w Comm sslor2 cvn �� i Teat BSc , WHAT IS YOUR PRESENT KN6WLEDGE OF THIS ADVISORY BOARD? r s Ch Gt eas S i t 1S . n ems, C�m�n -/ K`tee:_e � Lm WI'1AI GUN I KIM) I IUN1 GAN YUU MAKL I U I MIS AUVIbUKY LSUAKU KIZAWN FUKAPPLYiNG t L in m a:: he k, �rLOw4cc � t v e4s, �j 55 Q -C,5 1'A 'tk_ C_0mrn �n 4-T e f«-e h IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Z Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes r-INo (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 June 2012 Page 2 of 7 t�ogJ. � r BOARD, COMMISSION AND COMMITTEES ,M�� BUSINESS LISTING � CITY OF IOWA CITY Name of City f Diou-�l±, Board /Co mmission /Committee aUG Date 7 Z Zi Name 6/-Z0t / p s , . Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission ap licant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS o � C: NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature, Signature of parent/guardian (Youth Advisory Commission only): Address ?136Jhr -in y Aup- 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 June 2012 Page 3 of 7 Marian Karr From: connie cuttell <conniecuttell @gmail.com> Sent: Wednesday, July 18, 2012 10:14 AM To: Council Subject: Diversity Ad Hoc Committee This correspondence will become a public record. To: City Council Members, I am writing to endorse the application of Orville Townsend, Sr. for appointment to the newly established Diversity Ad Hoc committee. Mr. Townsend has been an informed and active member of the Iowa City Human Rights committee for nearly two years. He is a long time resident of Iowa City and is very well versed in the issues of diversity in our community. He would be an outstanding member of the ad hoc committee. Thank you. Connie Goeb ICHR Vice -Chair City of Iowa City 11 Advisory Board /Commission /Committee i ' " 't 1 replication Form CITY OF OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY /-66' ((' CONSIDERED FOR ANY VACANCY DURING THAT TIME. CAdvisory Board /Commission /Committee Name A � F , C", 11,;* s SST Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: It ,� „ �A _ ,, C� NAME _) L--r r ti 40 *-SS ja HOME ADDRESS Is your home address (listed above) within the corporate limits of Iowa City? How long have you been a resident of Iowa City? i C4 -7 8 `"2 6 /6 OCCUPATION Rell V6-(,k ��'(f��n �GQ� ,e --�JZ, EMPLOYER _ PHONE NUMBER: HOME K... �Lj D ` LO BUSINESS tq6 Yes Gender: Male No Female EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 4 C) ck-c, Cc- Ce,C J x1}37- �k QL U F&-q-Cro, C �;Meh Z4, c � " "A i��� R)tk� , WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? C- AA,) c k- I'e- (C:,A 13w-��Jel R GV— d % WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? " Cvl LIST POTENTIAL CONFLICTS OF INTEREST: See naae 1 for information reaardina Conflict of ifiterki IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes No' ' DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR C MISSION? r]Yes [gNo (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 answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 � r i BOARD, COMMISSION AND COMMITTEES A,,`1 °� BUSINESS LISTING,,`_ CITY OF IOWA CITY Name of City Z Board /Commission /Committee 4C— (!6-X- (M Date Name Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS OWN ZWFAN 9-tom ! NOTE: A new form acquired in an addi Applicant Signature_ Signature of parent/g Address f ,2 "D completed if the above information changes or an ownership hterest`is bisiness. ian ryouth Advisory Commission only a-j-, j q o q r-U-- A-- 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 June 2012 Page 3 of 7 City of Iowa City r Advisory Board /Commission /Committee'�`r' application Form -�-� CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Ad Hoc Diversity Committee Term Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Kingsley A. Botchway II HOME ADDRESS 260 Scott Ct. Ate, Iowa Cu . IA 52245 Is your home address (listed above) within the corporate limits of Iowa City? ❑✓ Yes ❑ No How long have you been a resident of Iowa City? 5 yrs Gender: Male Female OCCUPATION Dewy Auditor of Elections EMPLOYER Johnson County PHONE NUMBER: HOME 803- 394 -3905 BUSINESS 319_356.6nn4 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITtom: ` = *B.S. in Criminal Justice & Criminology from the University of South Carolina Juris Doctor from the University of Iowa College of Law - *Member of the Police Citizens Review Board *Former public transit employee & driver in Iowa City WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? " The committee will look into the needs of minority community members in Iowa City, specifically whefe they involve law enforcement and public transit. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? *legal experience with policies and procedures in regards to drug treatment and at -risk minority outreach programs *experience working with community through GED programs, troubled youth programs, & pro bono programs *experience with coordinating large scale efforts to help in community (flood cleanup, food service, mentorship, etc.) *experience as a frequent user of public transit and former employee & driver of public transit in Iowa City LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest N/A IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? n,/Yes n No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? QYes F—]No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fall to answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City . Board /Commission /Committee Ad Hoc Diversity Committee Name Kingsley A. Botchway II .. tt�; .Gfit � moms�� CITY OF IOWA CITY Date 4 1 k� l l Z Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS C> N NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. , Applicant Signature Signature of parent/guardian (Youtli�isory-Csion only): Address 260 Scott Ct. Apt. 3, Iowa City, IA 52245 Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 3 of 7 City of Iowa City _ ► r i Advisory Board/Commission/Committee;�`r'� *3plication Form CITY OF OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name AdHoc Diversity Committee Term AdHoc Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Donna Henry HOME ADDRESS 1926 Broadway St., Iowa City, Iowa Is your home address (listed above) within the corporate limits of Iowa City? [✓ Yes F] No How long have you been a resident of Iowa City? 10 Years Gender: Male r] Female 0✓ OCCUPATION Student and Human Service Worker EMPLOYER Broadway Neighborhood Center PHONE NUMBER: HOME 319- 338 -1557 BUSINESS 31A -3S4 -7999 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: JA a black woman I have experienced both intended and unintended consequences of both racial and economic :istice. I am raising two daughters who currently attend ICCSD schools. I work hard with my kids to help them (prepare for the future, they are already saving college money and my oldest daughter is working on scholarships through the Miss Iowa Teen Pageant. I am enrolled at KCC and will soon earn an AA degree in Human Services. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I attend neighborhood meetings and followed the development of this advisory board through neighborhood leaders. I know that an ad hoc committtee is temporary and advisory in in its nature but I am hopeful that it expands communication between Iowa City Government, the Police Department, and the hard working families that live in my neighborhood. I understand that transportation and police protection are the top priorities for the committee. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? I a represent many women who are the head of their household and responsibly balance their family and civic duties. I also have an academic background in Human Services. My kids work to achieve in school and in the community. Subtle systemic racism can make a difference in a child's potential. My motivation is to help create a more fair community for all families. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? r, /]Yes Nv DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSI.ON? Yes WINo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at ifie 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 June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee AdHoc Diversity Committee Name Donna Henry 1 l 141 k �►►►+ CITY OF IOWA CITY Date 07/13/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. , Applicant Signature420 -k� X-4e Signature of parent/guardian (Youth Advisory Address 1926 Broadway St., Iowa City, Iowa n only): Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 3 of 7 City of Iowa City _ r Advisory Board /Commission /Committee onplication FormMR CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. I Advisory Board /Commission /Committee Name Ad �f�G z1,Je- f,S*L4 Term � 12- -31 /a! 13 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME �o� �,) �,° �/ �n HOME ADDRESS 0132(o Ca Coyr+ S +o Is your home address (listed above) within the corporate limits of Iowa City? El Yes No How long have you been a resident of Iowa City? c q uecRf � Gender: Male Female OCCUPATION EMPLOYER PHONE NUMBER: HOME BUSINESS :XPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Qef-soncalld, 1 am jFczi'her of 3 A fr7cc)Ln Mme -ricer ,yoon� o,�Ows, plus nvmemos �5-(-�� c�l�� ldreno �tro55iosu�i��, ho.�e ler� c�eo,l�n8 tai Fo( over c)L0 vJeaxs WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I Loos prese.n+ o+ F7orrna ('on, an3 haue fblkotoe� of `fie C o r\c- (S Forrno,] a,n � _j,_orarmo0 k5cj55 ian S. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? F rs +, .T. core- �e�QI� e Sers}axe, 1: am no-h a�Fr-osiA 4-z� osK 4-mg `L`�e - 1- + °orzs ` -6i rz , LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict:oflnterest None of W h 77CK .Z aM au-are e IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 15�] Yes F-] No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes 'No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail a ) answer all the questions, Council may not consider your application. i General Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES h BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee -" m e- , f Date % )oZ Name ECA lso w a f) Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature, a Signature of parent/guardian (Youth Advisory Commission only): Address Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 3 of 7 City of Iowa City r i tea._. ®afi Advisory Board /Commission /Committee;, "';'� ion Form T .pplicat �-�- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Ad Hoc Diversity Committee Tehn 6 months Youth Advisory Commission (shall not be more than 18 years of age at the tirn"f application) Name of Iowa City High School or high school equivalent: e -- - -A Signature of parent/guardian: NAME Charlie Eastham HOME ADDRESS 37 Colwyn Ct. Is your home address (listed above) within the corporate limits of Iowa City? ❑✓ Yes F] No How long have you been a resident of Iowa City? 41 years Gender: Male 0✓ Female OCCUPATION retired EMPLOYER retired PHONE NUMBER: HOME 319 541 -3972 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: rer the past two to three years I have been an active participant with the Coalition for Racial Justice, the FasTrac ,,,divsory Board, the Immigrant Voices Project, the Sanctuary City Committee and the Immigration Roundtable. For the past twenty years I have served on the Board of Trustees of The Housing Fellowship. I am also on the Planning and Zoning Commission. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? The Council has charged the Diversity Committee to study the operation of the transit system, including the downtown interchange, and City law enforcement, including the PCRB, as these services relate to minority populations and to consider recommendations which may promote further just and harmonius interactions between City government and minority segments of the community. The Committee has 6 months to complete its work. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORAPPLYING ? During the past few years I have had the opportunity to hear many voices in various minority communities express their perceptions and experiences regarding being a resident of Iowa City. I believe I can fairly and honestly bring what I have heard to the work of the Diversity Committee. I also believe my experience with the Planning and Zoning Commission will make sure my viewpoints remain within the charge given by the Council to the Committee. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest none IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ❑✓ Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes F1No (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 Reset Form June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES° BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee Ad Hoc Diversity Committee Date 07/16/2012 Name Charlie Eastham Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applican t, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature After printing, please sign here Signature of parent/guardian (Youth Advisory Commission only): Address 37 Colwvn Ct. 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 June 2012 Page 3 of 7 City of Iowa City I r 1 Advisory Board /Commission /Committee k�--I °; lication Form ;pp CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Ad kos Q i ` tyr t�- Co w w+ 0+e-e- Term { monih s, Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Bakhi HOME ADDRESS 2610 f too- e-4 12A. �&Z -14 10 I&W-A J A 522 6 Is your home address (listed above) within the corporate limits of Iowa City? Yes R No How long have you been a resident of Iowa City? y eckv `�, Gender: Male © Female F1 OCCUPATION S:�--tk a9 V�f EMPLOYER PHONE NUMBER: HOME `319 - 3331 6 1 b1 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 1 aVVI Ue�h +We w. A-�k sA- a« Q A& c� M vVI ►'- k( _ rt la `d � Goa � � 6oavel �'✓`Q s � I vJ � ` Q �stlCKcevts kmcv iccav "icas (hc. lam mkSo pexv.� d� � �Lv.vA' c vcavk Qo;rc s F J cvAS a .� 't � sk- ev,'�.�� C�mwi`i Ii t-- Q WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? CoLLvAc G ec h' we can ��{ -��P �, .( ►�s�l,��a � - ; WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR -A t s C .tAJL S LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? F)I( Yes F-1 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? []Yes ©No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail l to answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 c�� C o cn� u u< t i e S GLvi cQ �� JZ� �d S a t s C .tAJL S LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? F)I( Yes F-1 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? []Yes ©No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail l to answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 1 b 1 r •= 4 BOARD, COMMISSION AND COMMITTEES 1 *�n'V &IN rN=I - BUSINESS LISTING - ,.ti,,a._ CITY OF IOWA CITY Name of City �n Board /Commission /Committee AJ Rca 'D i Q evv 3 4u Ca n w, c iiep Date Q (Iq 2d 1f2 NameQi� Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature Signature of parent/guardian (Youth Advisory Commission only): Address 26 10 12& v4v-[ t Q� . App- P IQ lower �''.-� J A !M 4, 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 June 2012 Page 3 of 7 City of Iowa City it r 1 Advisory Board /Commission /Committee '��I , t nplication Form -�-- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Diversity Committee Term Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME R,64cr2a �.,� 2 �'L HOME ADDRESS I C -Zuc- Is your home address (listed above) within the corporate limits of Iowa City? es No How long have you been a resident of Iowa City? 19 \1 P�� Gender: Male � Female cl— OCCUPATION �a'M� -��/ Ca i 0. `r I EMPLOYER CC ( A- ZAnt� .r," Cc--13 PHONE NUMBER: HOME (�@S2- (-x-71-9 BUSINESS XPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 'W v�'1� crv� �c� -e_S •��' 1r- eS�,�c.eS ��' '� -�^'�. (<.�S WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYINGV? �•v�s�1+.Jt e°( �.�1 { ��`�- l"'"vt C u ✓ 4� Ij { LIST POTENTIAL CONFLICTS OF INTEREST: See pane 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Q Yes R No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? F]Yes FNo (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 answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Name Diversity Committee CITY OF IOWA CITY Date 0"(12-311Z_ Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NOTE: A new form must be co ted if the above information changes or an ownership interest is acquired in an a i i al busine s Applicant Signature, Signature of parent/ Address V"�A_Aln i ardian (Youth Advisory Commission only): _ Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 3 of 7 City of Iowa City. r i Advisory Board /Commission /Committee; "' .pplication Form CITY OF OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. I )`�d�� Term Advisory Board /Commission /Committee Name 1��- k Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME 1k Cep MM IVU� Q_ HOME ADDRESS Is your home address (listed about) within the corporate limits of Iowa City? �es F] No How long have you been a resident f Iowa City? cis Gender: Male 11 Female cJ OCCUPATION ,' C ooi� EMPLOYER JAM 1 PHONE NUMBER: HOME 319 % O M BUSINESS 53101 9,n(o 65q EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: � cd C& � L6 i Vve- ' Dec* 4 IiG`�vyv�c St-v0 Y, of r �I�11cz�sz jM► rri �nv►�r"� -� �1�1 -tYIC� '' _ I— �'►`U ir1 e >r- �% L AraA OEM �Nlol cpv �OAJJ)d WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I -= 3L i� �-h'li ��� S ((����.`i'Cl c (b l Z � PMCfi`U 1 �" D �L u� W - CC r� D� l Aht tGACl la, .0 [mac, ck- L /1 e 1-k- - L tz"C 'fYt�c�t�n (in ' Ce>riy�1►(�� rb4 -vcl -�Al czyly\h�2nct �c \3r� _ fib Mkk o -6W IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [:] Yes F-] No / DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? [ Yes M4 o (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES ► h BUSINESS LISTING CITY OF IOWA CITY Name of City , L Board /Commission /Committee 1 M Date> 7/ Name Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the�bove information changes or an ownership interest is acquired in an addNo usiness. 7 Applicant Sign, Signature of pa Address `J outk,4dvisory Commission only): Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 3 of 7 City of Iowa City I r 1 Advisory Board /Commission /Committee t *)plication Form CITY OF OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME/. Advisory Board /Commission /Committee Name - _13 Term 6'y Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent /guardian: NAME �D n A Lt- > HOME ADDRESS Is your home address (listed above) within the corporate limits of Iowa City? Yes F1 No How long have you been a resident of Iowa City? 6"", Gender: Male r7f Female OCCUPATION iw ,Pryk�c� EMPLOYER PHONE NUMBER: HOME 31� 1�` �(°� BUSINESS cvocolcnlrrc A AIMAM erTIVITIGC WW1f'_41 YO11 FFFI (]I Idl IFY Yf)I I FOR THIS POSITION- 1­0 WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? ,+ 1 -- WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? l;; a ✓l .�``:� y VC iL g �Qv T e i e s , pe P 4 Av,,0 , A-, Pe7 LIST POTENTIAL CONFLICTS OF INTEREST: : See page i for Information regarding tronTlICT or Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 2 Yes u No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? E2"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 June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING 11 r 1 CITY OF IOWA CITY Name of City Board /Commission /Committee P�D 4c-- vr, wl)� kvc-z�' Date Name DpvXAL-7 7 -;IN -1Z Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS 11 NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature_ Signature of parent /g Address .�3 7L( ian (Youth Udvisory Commission only): Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application June 2012 Page 3 of 7 City of Iowa City _ r Advisory Board /Commission /CommitteeNMr' I . pplication Form - - CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Diversity Committee Term n/a Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Joan Vanden Berg HOME ADDRESS 3o9 Fairview Avenue, Iowa City Is your home address (listed above) within the corporate limits of Iowa City? ✓❑ Yes F-] No How long have you been a resident of Iowa City? 32 years Gender: Male ❑ Female ✓� OCCUPATION Social Worker EMPLOYER Iowa City Community School District PHONE NUMBER: HOME (319) 354 -2867 BUSINESS r31A) r;33 -1n1s EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: i primary focus of my professional life has been to increase opportunities for low- income youth and families in our uummunity. Over the past 28 years I've developed numerous programs for low- income and minority youth, but more importantly I have learned so much from listening to the youth and families whose life experiences -are far different from my own. - WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? It is my understanding that this adhoc committee is being convened to develop concrete act�oris steps foY hdw we can support our minority population,with a particular focus on transit and law enforcement: == _° WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYINGI? I can serve as a liaison to the schools and our numerous partner organizations. I can share district data and information about resources with the committee. Likewise, I would be able to seek input from families via Family Resource Center and other district staff who work daily with minority families in every Iowa City school / neighborhood. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest On behalf of the district I have requested from the City of Iowa City a 50% discount on youth bus passes, and in the past the district has applied for CDBG funds. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? V✓ Yes [-] No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? FYes W71 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 I to answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Diversity Committee Name Joan Vanden Berg CITY OF IOWA CITY Date 07/24/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional busine,5s. Applicant Signature Signature of parent/guardian (Youth Advisory Commi6ion only): Address 309 Fairview Avenue, Iowa City 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 June 2012 Page 3 of 7 City of Iowa City _ r Advisory Board /Commission /Committee � w= -, P -)plication Form -^�- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLYAND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Ad Hoc Diversity Committee Terra first -term Youth Advisory Commission (shall not be more than 18 years of age at the time- -of ap�licatO Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Cindy Roberts HOME ADDRESS 2034 Grantwood `Street Is your home address (listed above) within the corporate limits of Iowa City? ✓0 Yes F] No How long have you been a resident of Iowa City? 27 years Gender: Male F Female OCCUPATION Administrator EMPLOYER University of Iowa - since 1985 PHONE NUMBER: HOME /cell 319- 330 -6734 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I h-lieve I can bring a helpful perspective from the viewpoint of a long -time (25 yrs) Grant Wood resident, volunteer work for the Grant Wood Neighborhood Association,my past volunteer work for GW Elem, and raising children in the GW neigh borhood.The GW neighborhood is a mix of socioeconomic and ethnic backgrounds, young families, retirees, elderly, single parent families, students, and more - -a neighborhood I love! WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I've followed the initial proposals, discussions, and development of this ad hoc committee via city council work sessions, regular council meetings, as well as online meeting minutes. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? Discussions centered around diversity are varied and complex. It's critical this committee bring together a variety of individuals from various backgrounds and that all members are capable of looking at the topics /issues from a balanced and inclusive perspective. This is how we create mutual understanding, move beyond perceived differences and move forward. I believe I can contribute to this type of civil and respectful dialogue and dynamic. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest I'm not aware of any conflicts of interests. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? a Yes FJ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes QNo (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 co answer all the questions, Council may not consider your application. General Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES,,`1 °�'� BUSINESS LISTING CITY OF IOWA CITY Name of City � Board /Commission /Committee Ad Hoc Diversity Committee Date Name Cindy Roberts Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS none NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. 1-11� Applicant Signature U \- a' Signature of parent/guardian (Youth AdVl sCommission only): Address 2034 Grantwood Street 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 June 2012 Page 3 of 7 City of Iowa City Advisory Board /Commission /Committee �:�r`'� "application Form �-�-- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Ad Hoc Diversity Committee Term 1 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: t NAME Mary (Polly) Nichols - Marshall H t AUUKt55 r;21 Rrnwn Street a Is your home address (listed above) within the corporate limits of Iowa City? 0 Y s � How long have you been a resident of Iowa City? 41 gears Gender: Male E- Female OCCUPATION retired -- adjunct assistant professor EMPLOYER Dept. of ChildlAdol. Psy&try, UIHC PHONE NUMBER: HOME 319- 338 -5704 BUSINESS ssg -4ggo EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL FOR THIS POSITION: I I am a white woman who believes that the purpose of this committee is to provide black citizens a forum to speak -''rectly to city government of their ideas for an equitable and just community for all. I believe my broad perspective, ,bing grown up in a white Iowa family who did not condone overt racism but who nevertheless was embued with (the notions of white priviledge and unintended but powerful institutional racism, are needed for full understanding. WueT IQ WHIP aIZFSFNT KM0WLEDGE OF THIS ADVISORY BOARD? WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REA50N FUKAPPLYINU _r I recognized my own racism as a young adult and switched directions in my career to studying moral development and serving those on the margins (education and psychology.) I've served on the boards of UAY, BBBS, and Eldora and am now on those of the Board of Supervisors' Juvenile Justice Youth Development Program and NAMI. 1 am a trained and effective problem - solver fo schools, agencies, and kids - -I have 8 mixed -race and 5 white grandchildren! LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [Z ]Yes "No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes ONo (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. _aneral Application June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING ► r 1 � . ®4 L m wr ®� CITY OF IOWA CITY Name of City Board /Commission /Committee Ad Hoc Diversity Committee Date 07/25/2012 Name Mary (Polly) Nichols- Marshall Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS there are none IT NOTE: A new form must be completed if the above information changes or an ownershij�Ynterest is acquired in an additional business. Applicant Signature Signature of parent/guardian (Youth Advisory Commission only): Address 621 Brown Street 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. — aneral Application June 2012 Page 3 of 7 Marian Karr From: Polly Nichols Marshall <pollymn @g mail. com> Sent: Thursday, July 26, 2012 10:41 AM To: Council Cc: Carrie Z. Norton Subject: forwarded email from Carrie Norton re Ad Hoc Diversity Committee This correspondence will become a public record. Council Members: Carrie Norton sent this to me as she was leaving town for a painting vacation and asked that I forward it to you when I had submitted my application for the Ad Hoc Diversity Committee. Her letter contains one error -4 directed out- and inpatient educational services for Child Psychiatry, not the entire outpatient clinic, though that is where Carrie and I often consulted together on youngsters with educational and psychiatric problems. Polly Nichols - Marshall Polly Nichols - Marshall h- 319.338.5704 c -319- 621 -8480 Carrie Z. Norton =46 _hotmail.com to me 19--, I am writing in support of Polly Nichols' application to serve on the City Council's Ad Hoc Committee for Diversity. Polly and I have, over the years, been professional colleagues and friends. I always loved working with Polly when she was the Director of Outpatient Services at UIHC Department of Child Psychiatry. She ran a well managed, high caliber outpatient clinic and I enjoyed and benefited from her knowledgeable and astute leadership. Most recently we have both been drawn to the meetings of the Coalition for Racial Justice. Although each of is engaged in many community activities - -Polly directs operations for the Coralville Food Pantry, and she's involved with The Consultation of Religious Communities and the local chapter of NAMI, the National Alliance on Mental Illness- - the Coalition meetings compel us to get involved as we learn of some of the racial issues extant in our community. As I cannot commit to another volunteer activity at this juncture and have myself decided not to apply for this important committee, I was delighted when Polly indicated she indeed, despite other obligations, would apply. Polly Nichols is the perfect applicant. I hope you choose to appoint her. M 17b NOTICE THE CITY COUNCIL OF IOWA CITY 1S CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: AIRPORT COMMISSION One Vacancy — Unexpired Term Effective Upon Appointment - March 1, 2014 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, July 25, 2012. 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 Michael Tharp, Airport Operations Specialist at 356 -5045. Airport Commission ATTENDANCE RECORD 2012 Key: X = Present X/E = Present for Part of Meeting O = Absent O/E = Absent/Excused NM = Not a Member at this time TERM 0 0 0 0 0 0 0 NAME EXP. (0 rn Cn Cn N N N N N N N 03/01/13 X X X X X X X Rick Mascari 03/01/14 X X X X X X X Howard Horan Minnetta 03/01/15 X X X X X O/ X Gardinier E Jose 03/02/12 O/E X X X X X X Assouline Key: X = Present X/E = Present for Part of Meeting O = Absent O/E = Absent/Excused NM = Not a Member at this time 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: 3 Females: Council Announcement Date: January 24, 2012; March 6, 2012; April 3, 2012, May 1, 2012; June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012, 2012 Council Appointment Date: July 31, 2012 After 04/24/2012 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AIRPORT COMMISSION One vacancy — Unexpired Term Effective Upon Appointment - March 1, 2014 Steve Crane resigned Gender Balance Requirement: None (F) Christine Ogren El 140 Cardiff. Cir 0 Denotes applicant completed the Confidential page of the application. City of Iowa City r 1 Advisory Board /Commission /Committee' r' h -3plication Form -�-� CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Airport Commission Term-, ends 31112014 Youth Advisory Commission (shall not be more than 18 years of age at the time`ctf-.,application)' Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Christine A. Ogren HOME ADDRESS 140 Cardiff Circle,_ bWa ajhL52246 ' Is your home address (listed above) within the corporate limits of Iowa City? 0 Yes Q No How long have you been a resident of Iowa City? 13 years: since 7/1999 Gender: Male F-1 Female 0 OCCUPATION professor (Educ_ Policy & Leadership Studies) EMPLOYER University of Iowa PHONE NUMBER: HOME 319.338.8253 BUSINESS n1A nns 5202 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: In the last ten years, I have volunteered for numerous events at the Iowa City Airport, including the Air Race Classic I many Experimental Aircraft Association activities. My husband is building an airplane which we plan eventually to house at the Iowa City Airport. Outside of aviation, I have leadership experience in professional organizations, having served as secretary of one association and currently completing my term on the board of directors of another. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I know former members of the Airport Commission, and recently spoke with current member Rick Mascari and Airport Operations Specialist Mike Tharp about serving on the commission. They were informative and encouraging. I also met with Minnetta Gardinier, another current member of the Commission. She provided useful insight and further encouragement. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? My experience with stewardship and leadership in national and local organizations has helped prepare me to bring the skills of critical analysis and organization to the Airport Commission. I will also contribute by bringing energy and a high level of interest in aviation. I am applying because this position would allow me to combine my interest in aviation with my desire to continue my involvement in the Iowa City community. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest My only potential conflicts of interest relate to my employment by the University of Iowa and plans to eventually rent a hangar at the airport. I would recuse myself from voting on related issues such as hangar rental rates. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? F✓ Yes F-1 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes WINo (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 June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Airport Commission Name Christine A. Ogren � r CITY OF IOWA CITY Date 07/19/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature_�C Signature of parent/guardian (Y Advisory Commission only): Address 140 Cardiff Circle, Iowa City 52246 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 June 2012 Page 3 of 7 Christine A. Ogren 140 Cardiff Circle Iowa City, IA 52246 July 19, 2012 Mayor Matt Hayek and City Council City of Iowa City 410 East Washington Street Iowa City, IA 52240 Dear Mayor Hayek and Council Members: Attached is my application for the open position on the Airport Commission. I have learned about the Commission from current members and the Airport Operations Specialist, and think that my interest in aviation and volunteer activities at the Iowa City Airport, my leadership experiences outside of aviation, and my desire to continue my involvement in the Iowa City community make me an excellent candidate for this position. I moved to Iowa City in 1999 with a longstanding interest in aviation, especially its history. Fortunate to meet others who shared my interest, I soon joined the local chapter of the Experimental Aircraft Association (EAA) and began volunteering for numerous events at the Iowa City Airport. I have helped orient passengers for rides in the EAA's Ford Trimotor and replica of the Spirit of St. Louis, helped with "Young Eagles" rides for children, and assisted women pilots who came to Iowa City to begin the 2011 Air Race Classic. I met my husband through the local chapter of the EAA; he is building an airplane which we plan eventually to house at the Iowa City Airport. Outside of aviation, I have leadership experience in national professional organizations and a local society. I served as secretary of Division F (History) of the American Educational Research Association and am currently completing my term on the History of Education Society's board of directors. In the latter position, I have participated in decision - making on budgetary and other issues. Closer to home, I have served actively on Johnson County Historical Society (JCHS) committees, including the Schoolhouse Interactive Committee in the early 2000s and the planning committee for the Johnson County Country School celebration which took place over four days in August 2011. 1 enjoyed contributing to and forming new connections within the community through my involvement in JCHS. My experience with stewardship and leadership in other organizations has helped prepare me to bring the skills of critical analysis and organization to the Airport Commission. I will also contribute by bringing energy and a high level of interest in aviation. I am excited to combine my interest in aviation with continuing involvement in the Iowa City community. I would be happy to further discuss my candidacy or answer any questions; my contact information is on the attached application, _.- Sincerely, Christine A. Ogren ° "? 17c NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: AIRPORT ZONING BOARD OF ADJUSTMENT One vacancy — Five -Year Term January 1, 2012 - December 31, 2016 The powers and duties of the Airport Zoning Board of Adjustment are: 1. To hear and decide appeals where it is alleged there is an error in any order, requirement, decision, or determination made by an administrative official in the enforcement of the Airport Zoning Chapter. 2. To hear and decide special exceptions to the terms of the Airport Zoning Chapter upon which such board is required to pass under the Airport Zoning Chapter. 3. To authorize upon appeal in specific cases such variance from the terms of the Airport Zoning Chapter as will not be contrary to the public interest, where owing to special conditions a literal enforcement of the provisions of the Airport Zoning Chapter will result in unnecessary hardship, and so that the spirit of the Airport Zoning Chapter shall be observed and substantial justice done. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets at the call of the Chairperson. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. The City 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 Johnson County/Iowa City Airport Zoning Board of Adjustment should be directed to Michael Tharp, Airport Operations Specialist at 356 -5045. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 1 Females: 1 Council Announcement Date: December 6, 2011; January 24, 2012; March 6, 2012; April 3, 2012, May 1, 2012; June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 03/05/2012 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AIRPORT ZONING BOARD OF ADJUSTMENT One vacancy — Five -Year Term January 1, 2012 — December 31, 2016 New Full Term Gender Balance Requirement: None No applications as of Wednesday, 5:OOp.m., July 25, 2012 0 Denotes applicant completed the Confidential page of the application. M NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: AIRPORT ZONING BOARD OF ADJUSTMENT One vacancy — Five -Year Term January 1, 2009 - December 31, 2013 The powers and duties of the Airport Zoning Board of Adjustment are: 1. To hear and decide appeals where it is alleged there is an error in any order, requirement, decision, or determination made by an administrative official in the enforcement of the Airport Zoning Chapter. 2. To hear and decide special exceptions to the terms of the Airport Zoning Chapter upon which such board is required to pass under the Airport Zoning Chapter. 3. To authorize upon appeal in specific cases such variance from the terms of the Airport Zoning Chapter as will not be contrary to the public interest, where owing to special conditions a literal enforcement of the provisions of the Airport Zoning Chapter will result in unnecessary hardship, and so that the spirit of the Airport Zoning Chapter shall be observed and substantial justice done. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets at the call of the Chairperson. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. The City 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 Johnson County/Iowa City Airport Zoning Board of Adjustment should be directed to Michael Tharp, Airport Operations Specialist at 356 -5045. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 1 Females: 1 Council Announcement Date: September 23, 2008; November 3, 2008; December 16, 2008; February 10, 2009; March 10, 2009; April 6, 2009; May 19, 2009; June 16, 2009; July 28, 2009; September 15, 2009; October 20, 2009; December 1, 2009; January 25, 2010; March 2, 2010; April 6, 2010; May 10, 2010; June 15, 2010; August 17, 2010 (Gender Balance in Effect); September 21, 2010; November 16, 2010; December 7, 2010; January 10, 2011; February 15, 2011; March 22, 2011; May 3, 2011; June 7, 2011; August 2, 2011; September 6, 2011; October 4, 2011; November 1, 2011; December 6, 2012; January 24, 2012; March 6, 2012; April 3, 2012, May 1, 2012; June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 11/15/10 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AIRPORT ZONING BOARD OF ADJUSTMENT One Vacancy - Five -Year Term January 1, 2009 - December 31, 2013 Term expires for Dennis Keitel Gender Balance Requirement: None No applications as of Wednesday, 5:OOp.m., July 25, 2012 0 Denotes applicant completed the Confidential page of the application. Z07 -31 -12 17e NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: AIRPORT ZONING COMMISSION One vacancy — Six -yr Term January 1, 2010 - December 31, 2015 Duties of the Airport Zoning Commission are: 1. To recommend amendments to the current Iowa City Airport Zoning regulations, including the repeal thereof. 2. To recommend the adoption of new Airport Zoning regulations. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets as required. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. The City of Iowa City encourages diversity in the appointment of citizens to boards and commissions. Persons interested in being considered should contact the City Clerk at City Hall, 410 E. Washington Street. Application forms are available from the Clerk's office upon request or on the City website at www.icgov.org. Questions about the Iowa City Airport Zoning Commission should be directed to Michael Tharp, Airport Operations Specialist at 356 -5045. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step- child, aunt, or uncle. (Resolution 85 -354) Males: 1 Females: 1 Council Announcement Date: September 15, 2009; November 2, 2009; December 1, 2009; January 25, 2010; March 2, 2010; April 6, 2010; May 10, 2010June 15, 2010; August 17, 2010 (Gender Balance in Effect); September 21, 2010; November 16, 2010; December 7, 2010; January 10, 2011; February 15, 2011; March 22, 2011, May 3, 2011; June 7, 2011; August 2, 2011; September 6, 2011; October 4, 2011; November 1, 2011; December 6, 2011; January 24, 2012; March 6, 2012; April 3, 2012, May 1, 2012; June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 11/15/10 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AIRPORT ZONING COMMISSION One Vacancy - Six -year Term January 1, 2010 - December 31, 2015 Term expires for Brian Sponcil Gender Balance Requirement: None No applications as of Wednesday, 5:OOp.m., July 25, 2012 0 Denotes applicant completed the Confidential page of the application. 17f NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: AIRPORT ZONING COMMISSION One vacancy — Six -yr Term January 1, 2012 - December 31, 2017 Duties of the Airport Zoning Commission are: 1. To recommend amendments to the current Iowa City Airport Zoning regulations, including the repeal thereof. 2. To recommend the adoption of new Airport Zoning regulations. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets as required. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. The City of Iowa City encourages diversity in the appointment of citizens to boards and commissions. Persons interested in being considered should contact the City Clerk at City Hall, 410 E. Washington Street. Application forms are available from the Clerk's office upon request or on the City website at www.icgov.org. Questions about the Iowa City Airport Zoning Commission should be directed to Michael Tharp, Airport Operations Specialist at 356 -5045. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 1 Females: 1 Council Announcement Date: December 6, 2011; January 24, 2012; March 6, 2012; April 3, 2012, May 1, 2012; June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 03105/2012 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AIRPORT ZONING COMMISSION One vacancy — Six -Year Term January 1, 2012 — December 31, 2017 New Full Term Gender Balance Requirement: None No applications as of Wednesday, 5:OOp.m., July 25, 2012 O Denotes applicant completed the Confidential page of the application. Z 7g NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: HOUSING & COMMUNITY DEVELOPMENT COMMISSION One Vacancy — Three -Year Term September 1, 2012 — September 1, 2015 Duties of the Housing and Community Development Commission include assessing and reviewing policies and planning documents related to the provision of housing, jobs, and services for low- and moderate - income residents; reviewing policies and programs of the Public Housing Authority and Community Development Division and make recommendations regarding the same to the City Council; reviewing and making recommendations to the City Council regarding the use of public funds to meet the needs of low- and moderate - income residents; housing policies and programs, and seeking public participation in assessing needs and identifying strategies to meet these needs; recommending to the City Council from time -to- time amendments, supplements, changes, and modifications to the Iowa City Housing Code. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. When possible, Council will appoint persons with expertise in construction and /or finance, a person receiving rental assistance, and a member of the Local Homeless Coordinating Board. The Housing and Community Development Commission will have monthly meetings. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. 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 Housing and Community Development Commission should be directed to Tracy Hightshoe, Community Development Planner at 356 -5244. ZOX M z > u u n O N �( :3 CD m c y a N 3 3 m 3 = D W ? _L 3 D O C- D m a Z v 3 n D r- m ° 0 � n z 2 I � = m r m a Z c 3 m Z m n m r m r c`o m m coo coo c`o M v > > J > N A W N W W A N A x x x x x m x x X I X X X x m X x te x x x x x x m x x cc x x x x x x m x x x x x x x m m m x co m x x x m x x x x -I m z v Nz Mn Nm m n O M c CO) z G) D z v 0 O 3 c z_ v m m r O -v m z q O FA- 3 3 O z x O c z G) z v 0 c z_ v m m r O m n O 3 CA 0 z Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 4 Females: 4 Council Announcement Date: May 15, 2012; July 10, 2012 Application Deadline: Wednesday, 5:00 p.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 08/13/2012 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. HOUSING & COMMUNITY DEVELOPMENT COMMISSION One Vacancy - Three -Year Term September 1, 2012 — September 1, 2015 Term expires for Jarrod Gatlin Gender Balance Requirement: None (M) Jarrod Gatlin 0 910 Benton Dr, Apt 11 (M) Dan Tallon 0 706 E Market (M) Michael Thompson 0 512 S 1 st Ave (Currently serving 1 st three yr term) 0 Denotes applicant completed the Confidential page of the application. Jul.16. 2012 2:52PM AMBULATORY CARE SRVCS City of Iowa City Advisory Board /Commission /Committee Application Form No. 2619 P. 2 A , I AN CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name _Housing and Community Development Term 201-L - BzAlb Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME d Gatlin HOME ADDRESS 910 Renton Dr API 11 Is your home address (listed above) within the corporate limits of Iowa City? F,/� Yes F-1 No How long have you been a resident of Iowa City? 2ayears Gender: Male a Female OCCUPATION Support Servicas SUpervonor EMPLOYER UIHC PHONE NUMBER: HOME 3199364800 BUSINESS 319�R47��4 _XPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 3 years experience on the commission with 1 year as Co -Chair person WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? In the last 3 years I have learned many of the monthly task and have gain additional knowledge regarding HUD C.:.F WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORAPPLYING ? I want to give back to community and assist with planning for these very important programs:._; ° LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for Information regarding Conflict-of Intetest None IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ❑✓ Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? F] Yes F,/JNo (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 answer all the questions, Council may not consider your application. HCDC Application June 2012 Page 2 of 8 Jul.16. 2012 2:52PM AMBULATORY CARE SRVCS No.2619 P. 3 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commissi on/Committee_ -D Date Zcno- Name Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page H). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there Are none. NOTE: A new form must be completed 'f the above information changes or an ownership interest is acquirgd in an a�ditipnal 4usil/ess. Signature Add Misrepresentations on this application will constitute just cause for removal of an appointee. F you fail to answer all the questions, Council may not consider your application. HCDC Application June 2012 Page 3 of 8 Jul,16, 2012 2:52PM AMBULATORY CARE SRVCS No,2619 P. 4 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 1061000 ATTACHMENT TO APPLICATION FOR THE HOUSING AND COMMUNITY DEVELOPMENT COMMISSION IN ORDER TO ENSURE THAT THE HOUSING AND COMMUNITY DEVELOPMENT COMMISSION IS REPRESENTATIVE OF THE COMMUNITY AND THE GROUP(S) WHICH IT SERVES, PLEASE INDICATE IF YOU ARE A MEMBER OF EITHER OF THE FOLLOWING CATEGORIES: 0 Lower Income (see table) FI Receive Rental Housing Assistance Your response is voluntary, and you may wish instead to elaborate on or indicate areas in which you can make a special contribution to the Commission in another section of this form_ When possible, Council will appoint a person or persons with expertise in construction, finance and /or a person receiving rental assistance. If you have expertise in construction or finance, please describe your experience &hd /or training. HCbC Application June 2012 page 4 of 8 City of Iowa City i r . ®a7 Advisory Board /Commission /Committee '� +®M�� " pplication Form -�-� CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. '­D Advisory Board /Commission /Committee Name Housing and Community Development Term Youth Advisory Commission (shall not be more than 18 years of age at the ti .ne ,of applicatioh) Name of Iowa City High School or high school equivalent: «.4 r •C..�' Signature of parent/guardian: NAME Dan Tallon HOME ADDRESS 706 E Market Is your home address (listed above) within the corporate limits of Iowa City? 0 Yes 'F] No How long have you been a resident of Iowa City? 5 years Gender: Male 0 Female F] OCCUPATION Soldier/ Student EMPLOYER Iowa Army National Guard PHONE NUMBER: HOME 319 5418204 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: rowing up, my family benefited from public housing assistance and my father continues to use this benefit. I have en very interested in helping others in Iowa City use the resources available to them to provide the best homes )ssible to Iowa City residents. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I understand that this advisory board assists the housing authority execute its duties with reccomandations on how to direct the program. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? I am applying because I have an interest in the serving on the board and wish to help others because I understand their situation. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest none. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 0 Yes FJ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes r—]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 i to answer all the questions, Council may not consider your application. HCDC Application June 2012 Page 2 of 8 1 � i BOARD, COMMISSION, & COMMITTEES - •a.a� BUSINESS LISTING CITY OP Iowa CITY Name of City Board /Commission /Committee Housing and Community Development Date 07/18/2012 Name Dan Tallon Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none BUSINESS NAME BUSINESS ADDRESS none none s• NOTE: Signature A new form must be completed if the above information changes or an ownership interest is acquired in n additional busine Address 706 E Market Iowa City, Iowa Misrepresentations on this application will constitute just cause for removal of an appointee. II �i If you fail to answer all the questions, Council may not consider your application. HCDC Application June 2012 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HOUSING AND COMMUNITY DEVELOPMENT COMMISSION IN ORDER TO ENSURE THAT THE HOUSING AND COMMUNITY DEVELOPMENT COMMISSION IS REPRESENTATIVE OF THE COMMUNITY AND THE GROUP(S) WHICH IT SERVES, PLEASE INDICATE IF YOU ARE A MEMBER OF EITHER OF THE FOLLOWING CATEGORIES: 0 Lower Income (see table) a Receive Rental Housing Assistance Your response is voluntary, and you may wish instead to elaborate on or indicate areas in which you can make a special contribution to the Commission in another section of this form. When possible, Council will appoint a person or persons with expertise in construction, finance and /or a person receiving rental assistance. If you have expertise in construction or finance, please describe your experience and /or training. HCDC Application June 2012 page 4 of 8 City of Iowa City r Advisory Board/Commission/Committee;�'r t nplication Form -�-� CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Housing and Community Dev. Commission Term 2012 to 2015 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Michael D. Thompson HOME ADDRESS 512 S_ 1 st Ave.- Iowa City , IA 52245 Is your home address (listed above) within the corporate limits of Iowa City? ❑ Yes F] No How long have you been a resident of Iowa City? 17 months Gender: Male ❑✓ Female OCCUPATION Business Attornev EMPLOYER Thompson & Thompson LLP PHONE NUMBER: HOME 312 - 907 -0430 BUSINESS 31A -24g -1270 c-� EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 1 vears of experience as a transactional attorney representing clients with respect to sales Qf 6usin6sses and other L Ness transactions, as well as with respect to compliance with applicable regulations. WHAT 15 YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? = The Housing and Community Development Commission is responsible for policies, planning and allopation of funds with respect to serving the needs of Iowa City's low and moderate income residents. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? Having lived for significant periods of time in Williamsburg (Iowa), Iowa City and Chicago, I have an appreciation for Iowa City's rare ability to combine the benefits of big -city living with small town charm. I will be interested in making recommendations that fit within the character of what makes Iowa City a wonderful place to live, and that are in the long -term interests of Iowa City and its residents. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest None IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? V✓ Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes W]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 .a answer all the questions, Council may not consider your application. HCDC Application June 2012 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Housing and Community Development Commission Name Michael D. Thompson 1 r , CITY OF IOWA CITY Date 07/18/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. I BUSINESS NAME I BUSINESS ADDRESS Thompson & Thompson LLP 1332 S. Linn St., Suite 28, Iowa City, IA 52240 NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Signature Address 512 S. 1st Ave., Iowa City, IA 52245 Misrepresentations on this application will constitute just cause for removal of an appointee. if you fail to answer all the questions, Council may not consider your application. HCDC Application June 2012 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HOUSING AND COMMUNITY DEVELOPMENT COMMISSION IN ORDER TO ENSURE THAT THE HOUSING AND COMMUNITY DEVELOPMENT COMMISSION IS REPRESENTATIVE OF THE COMMUNITY AND THE GROUP(S) WHICH IT SERVES, PLEASE INDICATE IF YOU ARE A MEMBER OF EITHER OF THE FOLLOWING CATEGORIES: Lower Income (see table) F-1 Receive Rental Housing Assistance Your response is voluntary, and you may wish instead to elaborate on or indicate areas in which you can make a special contribution to the Commission in another section of this form. When possible, Council will appoint a person or persons with expertise in construction, finance and /or a person receiving rental assistance. If you have expertise in construction or finance, please describe your experience and /or training, Business attorney that has worked on numerous transactions - currently taking classes part -time at Iowa towards completion of an MBA in finance. HCDC Application June 2012 page 4 of 8 17h NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: HUMAN RIGHTS COMMISSION One Vacancy — Unexpired Term Effective Upon Appointment - January 1, 2014 Duties of the Commission include: 1) disseminating information to educate the public on illegal discrimination and civil rights, such as organizing and facilitating educational public forums that address one or more of the broad range of topics included within the rubric of human rights; 2) making recommendations to the City Council for such further legislation concerning discrimination as it may deem necessary and desirable; 3) cooperating within the limits of any appropriations made for its operation with other agencies or organizations both public and private whose purposes are not inconsistent with those of Title 2 of the City Code (Human Rights Ordinance) and; 4) planning programs and activities designed to eliminate racial, religious, cultural and other intergroup tensions including but not limited to sex, color, creed, disability, gender identity, sexual orientation, marital status, age, and national origin. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Human Rights Commission meets the third Tuesday of each month at 6:00 p.m. in the Lobby Conference Room at City Hall, 410 E. Washington Street. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. The City of Iowa City encourages diversity in the appointment of citizens to boards and commissions. Persons interested in being considered should contact the City Clerk at City Hall, 410 E. Washington Street. Application forms are available from the Clerk's office upon request or on the City website at www.icgov.org. Questions about the Iowa City Human Rights Commission should be directed to Stefanie Bowers, Human Rights Coordinator at 356 -5022. Page 19 of 19 Human Rights Commission ATTENDANCE RECORD 2012 (Meetina Date) NAME TERM EXP. 1/17 2/21 3120 4/17 5/15 6/19 7/17 8/21 9/18 10/16 11/20 12118 Dr. Howard Cowen 1/1/13 X X O/E X O/E X Constance Goeb 1/1/13 X O/E X X O/E O/E Harry Olmstead (8 -1 -2010) 1/1/13 X X X X X X David B. Brown 1/1/14 X O/E O/E O/E R R R R R R R R Diane Finnerty 1/1/14 O/E X X X X X Orville Townsend,Sr. 1/1/14 X X X X X X Henri Harper 1/1/15 O/E X O/E R R R R R R R R R Kim Hanrahan 1/1/15 X X X X X X Shams Ghoneim 1/1/15 O/E X X X X X Jessie Harper (Appointed 6-5-12) 1/1/15 O/E KEY: X = Present O = Absent O/E = Absent/Excused NM = No meeting /No Quorum R = Resigned - = Not a Member Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 4 Females: 4 Council Announcement Date: June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 09/03/2012 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. HUMAN RIGHTS COMMISSION One vacancy — Unexpired Term Effective Upon Appointment — January 1, 2014 Henry Harper resigned Gender Balance Requirement: None (F) Nancy Pacha D 904 Scott Park Dr (F) Jill Schnoebelen 0 1128 Wylde Green Rd (F) Erika Harper 0 2 Dunuggan Ct (F) Kira Pasquesi 0 1728 Morningside Dr (M) Joe Dan Coulter Fx1 1818 N Dubuque St (F) Megan Schwalm M 914 Iowa Ave, #1 (M) Dan Tallon Fx1 706 E Market El Denotes applicant completed the Confidential page of the application. Ay of Iowa City � r Advisory Board /Commission /Committee;�-I °;' h Application Form CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Human Rights Commission Term ending 1/1/15 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Nancy Pacha HOME ADDRESS 904 Scott Park Drive Is your home address (listed above) within the corporate limits of Iowa City? ✓0 Yes F] No How long have you been a resident of Iowa City? 65 years Gender: Male ❑ Female OCCUPATION retired Spanish teacher EMPLOYER PHONE NUMBER: HOME 319 - 351 -6251 BUSINESS NSA EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: As Qr)anish teacher taught cultural differences, promoting understanding of different cultural expressions and regard fm ,m. I'm Methodist married to a Catholic, have gay family members and three adpoted granddaughters bom in Colombia. Have been a member of humanitarian missions in India, Mexico and Guatemala. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Aware of awards granted by commission and know some recipients. Have nominated many young people for Youth Human Rights Award. Have read info concerning workings of commission and spoken to former commission member Bev Witwer and also to Stefanie Bowers concerning responsibilities. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? I believe education and awareness are vehicles to break down discrimination and would like to be a part of that effort. If ability to speak Spanish can be an asset, I can offer that as well as enthusiasm for the work the.-commission does. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information reaarding Conflkjof inter t None IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 0✓ Yes -F] NQ DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 0 Yes allo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) srepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2 of 9 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Human Rights Commission Name Nancy Pacha � r j «1 CITY OF IOWA CITY Date 05/22/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS None NOTE: Signature A new form must be completed if the above information changes or an ownership interest is acquired in an add-ifional business. Address �L f seo cam% - =-N-t. '1.�� t A, 2-2-7 S~ isrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 ousehold Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 7 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shalt take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) OPTIONAL- PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 65 Age female Gender median+ Income (see table) heterosexual Sexual Orientation Other (Please explain below) Human Rights Commission Application January 2012 page 4 of 9 Methodist Religion None - I Disability Caucasian Race, color or ethnic group IUSA National origin u City of Iowa City i r Advisory Board /Commission /Committee'''' ' �..4 _pplication Form - ^-� -- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. ' 4-- Adviso Advisory Name -��U_mcv� Ri �fs Term X.,,- ,'7.ois Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME �i�,cJy1n+°lo e�e� HOME ADDRESS Iac� A -Q Gr -) AZPA c14 Is your home address (listed above) within the corporate limits of Iowa City? Yes ❑ No How long have you been a resident of Iowa City? 0120 `�a9? , dc�9-� fender: Male Female �}dY►vYtun. ;� OCCUPATION (�IQ, xkg� ,�ne,��i—(iv1%��tck{;on�Q e-duc,, EMPLOYER� PHONE NUMBER: HOME 3 330 -9 1 9,7 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: )rev�ays LJ ork. WN41 r-er, t c At- r a Pt t"-,1s Ih coxx► 4r+d} �b��.� /4� +'��c di ,� �voccac� P t 6- --+0 O p i�J �°� �an�1.o ;n �r1 lehi �G t l��e�*� LG(w 60Q ft11A.,, (� +5 tt" `° L Q t1Ce,4. o t e✓i o tug W v'r L d 0 trlji4 ui c)ls lcs2 J l ✓iv : A V 1 cu-% v a p a,. A1-9— WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? GC ►tit crn"� ��-1 WA +kQ GtC �+�i eA C 2,�� 0.0 o r.d. In"� I n LL '--O r© �► ak-{— "�'k.e T WHAT CONTRIBUTTIO N+ S CAN YOU MAKE TO1 THIS ADVISORY BOARD REASON FOR. bOOLYING ? ' F LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OIk COMMISSION? nYes EINo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) 'Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2.of 9 BOARD, COMMISSION, & COMMITTEES ..' BUSINESS LISTING CITY OF IOWA CITY Name of City ll l Board /Commission /Committee �1 Umc n �P); 4 4 S Date l Z Name Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS L C. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Signature Qv� � � Address / l �' ,�� iT� �3;fl cl -T-k- q% , 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. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. FM--M Gender I" Income (see table) Ii Sexual Orientation F70ther (Please explain below) Religion V Disability Race, color �'-�' or ethnic group National origin Human Rights Commission Application January 2012 page 4 of 9 City of Iowa City s j Advisory Board /Commission /Committee; Anplication Form -n-�- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Human Rights Commission Tart Unexpired Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME _Erika Hamer HOME ADDRESS 22 Quouggan r.64t , Ic y, IAA Is your home address (listed above) within the corporate limits of Iowa City? 7 Yes ❑ No How long have you been a resident of Iowa City? 1 year Gender: Male F'_1 Females OCCUPATION Media Producer EMPLOYER City of North Liberty PHONE NUMBER: HOME 319 -530 -3519 BUSINESS -i14_s2R_s,,7s7 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: F IV- work as the Promotion Producer for the City of North Liberty and NLTV allows me to exercise my passion for L ng involved with local churches, schools and organizations to promote their causes and events. Also, I produce live- coverage of all North Liberty public meetings; I'm familiar will the structure /order of city commissions /boards. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? As a new resident of Iowa City, I just recently discovered the Human Rights Commission. From the research that I've done, it appears that the commission is heavily involved with promoting the rights of people from all races, religions, ages, sexuality, etc. I believe that the commission also works with organizations that bring lecturers and events to IC. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? When I discovered that the City of Iowa City had a Human Rights Comm., I was very excited because I'm a strong believer in equality. I can bring passion to the commission, and I'd love to participate in public awareness. I can also bring new ideas and ways to promote events, programs and causes for human rights in Iowa City. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [7 Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes QNo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) 'ylisrepresentations on this application will constitute just cause for removal of an appointee. If you fail Lo answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2 of 9 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Human Rights Commission Name Erika Harper 1 - •t.ay_ CITY OF IOWA CITY Date 05/29/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Signature Address 2 Dunuggan Court, Iowa City, IA 52240 Misrepresentations on this application will constitute just cause for removal of an appointee. if you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80°x6 Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 1 29,900 49,800 59,760 79,700 991600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 27 Age Female Gender Income (see table) Lesbian Sexual Orientation F-10ther (Please explain below) F- I Religion Disability Caucasian Race, color or ethnic group National origin Human Rights Commission Application January 2012 page 4 of 9 City of Iowa City Advisory Board /Commission /Committee ,A nplication Form -�-�-- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLYAND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Human Rights Commission Term 3 years Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Kira Pasquesi HOME ADDRESS 1728 Morningside Dr. Is your home address (listed above) within the corporate limits of Iowa City? -✓ Yes � No How long have you been a resident of Iowa City? 2001 - 2005.2011-present Gender: Male F] Female W] OCCUPATION Doctoral student EMPLOYER University of Iowa PHONE NUMBER: HOME (630) 750 -0031 BUSINESS (3g) xy5 -6976 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: -e attached AIUA'r IQ vni io DDCQCKrr VK]r%XAn Gnf:G ng TWI-Q AnVIRnRV RnARn7 See attached „! WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLY60)? See attached LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest None (F YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? U Yes "No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? FlYes 7No (:It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail } to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2 of 9 f BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING CITY OF IOWA CITY Name of City 1 Board /Commission /Committee Human Relations Commission Date 05/05/2012 Name Kira Pasquesi `Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS None Cam; NOTE Signature A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Address 1728 Morningside Dr. Iowa City, IA 52245 Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11-8-94) PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 28 Age Female Gender Low Income (see table) Heterosexual Sexual Orientation F-1 Other (Please explain below) Agnostic Atheist Religion Able- bodied Disability White Race, color or ethnic group U.S. National origin Human Rights Commission Application January 2012 page 4 of 9 Kira Pasquesi Human Relations Commission Experience and/or activities which you feel qualify you for this position I have experience as a community organizer and dialogue facilitator working with underserved populations. While in Colorado Springs, the last place I resided and worked, I coordinated efforts to better access the needs of diverse populations, such as immigrants and refugees and clientele of the neighborhood community centers. Additionally, I served as a member of the Colorado Springs Parks, Recreations, and Cultural Services Advisory Board and provided funding, procedural, and programmatic recommendations to City Council for a city of approximately 600,000 people. In my role as the Outreach Programs Coordinator at Colorado College, I facilitated difficult dialogues on privilege and oppression with college faculty and students in a variety of programs. We discussed challenging issues like race, class, sexual orientation, gender, gender identity, and religion, and considered how to work for social justice at an organizational and individual level. I continue to pursue my interests in equity and inclusion at the University of Iowa. Last semester, I co- taught a course titled "Multiculturalism in Higher Education" and supported students in their exploration of personal and intergroup identity. Board Member, Parks, Recreation and Cultural Services Advisory Board, June 2008 -July 2011 City of Colorado Springs, CO • Advised city council on decisions related to 274 parks in addition to trails, open space, cultural services and recreation • Represented the board on a municipal task force to facilitate a public planning process for the d_ elopment of the Manitou Springs Incline, a nationally recognized trail and local attraction ` J ; organizer, Food for Thought Project, March 2010 -July 2011' versity Forum - Colorado Springs, CO La • Recruited and trained facilitators for community discussion groups that take place in citiz_e_ris' homes to promote civil discourse and active listening across difference y • Facilitated a pilot program group and provided detailed feedback to improve program structure and impact Organizer, Community Center Task Force, September 2009 - October 2010 Various Community Organizations- Colorado Springs, CO • Organized three neighborhood dialogues for 75 participants to access issues and assets related to the community centers • Assembled a five -hour task force strategic planning retreat to develop and prioritize organizational goals in order to better advocate for sustainable funding for local community centers in the face of significant budget cuts Organizer, Dream City Vision 2020 Project, January 2009 -May 2010 Leadership Pikes Peak - Colorado Springs, CO • Crafted a dialogue agenda and trained volunteers as facilitators alongside the national organization Everyday Democracy • Facilitated over 50 one -hour community visioning sessions with small groups of diverse citizens and a corresponding study circle to analyze data and develop community engagement vision statements for the Pikes Peak Region Co- Chair, Quality of Life Community Engagement Vision Council, September 2008 -July 2011 Pikes Peak United Way- Colorado Springs, CO ■ Lead a 12 person council made up of citizens committed to documenting local community engagement efforts ■ Researched and analyzed voter participation data and recommend future course of action as part of the community engagement chapter in an annual publication on the quality of life in the Pikes Peak Region Board Member, Pikes Peak Immigrant and Refugee Collaborative, September 2007 -July 2011 Partnership between Colorado College, Colorado Trust and Catholic Charities ■ Organized five community dialogues utilizing the Everyday Democracy study circles model for over 300 participants with the goals of increasing immigrant integration in our community —nildren's Activity Chair, `Everybody Welcome' Diversity Festival, April 2008- Present Diversity Forum - Colorado Springs, CO • Chaired a committee of Diversity Forum volunteers and facilitated monthly meetings • Contacted performing art groups, organizations, and local non - profits about participation in festival children's activities Outreach Programs Coordinator, Colorado College, August 2007 -July 2011 Colorado Springs, Colorado • Coordinated a Public Achievement program of 100 middle/high school students, 30 college students, and 12 cooperating teachers that pairs small groups of students with college "coaches" to develop social action projects • Trained engaged faculty in service - learning and community -based research through workshops and course development sessions • Designed a leadership certificate that ties curricular and co- curricular experiences in social action through guided critical reflection and advising relationships • Created a residential program curriculum on the art of community organizing that combines social change theory with practical application of skills and organizing tactics in team projects What is your present knowledge of this advisory board? The Human Relations Commission plans programs and activities, such as the recent event "Building Relationships and Creating Opportunity in the African American Community: A Panel of Parents and Youth of Color ", in order to facilitate understanding between groups and work to eliminate tensions in our community. The commission raises critical - nestions related to human relations issues, such as such as racism, sexism, ableism, and heterosexism, and disseminates _brmation about civil rights and discrimination to the public. The commission also provides recommendations to City Council on necessary legislation related to issues of discrimination and cooperates with outside public and private agencies or organizations. What contributions can you make to this advisory board? I would bring a unique perspective to the Human Relations Commission with my interest and experience in community organizing and dialogue. Dialogue allows people of different backgrounds to talk honestly about public issues and learn from each other's experience. It can serve as a foundation for public action and facilitate shared knowledge, resources, and decision - making. I am a trained facilitator and organizer in the Everyday Democracy model of dialogue. I applied this model to various community- oriented dialogue projects and brought together diverse groups of people to address shared issues of concern. While in Colorado Springs, I worked with our local community centers to better understand the needs and assets of the populations being served. We formed a task force comprised of neighborhood leaders and community center clientele to find solutions to budget shortfalls. The Community Center Task Force was successful in keeping the Colorado Springs community centers open and the city transitioned to a new model of governance and funding for the centers. It is important for me to be an active and engaged member of my community and I am excited about the opportunity to contribute time, energy, and passion to a commission that works to improve Iowa City for all its- residents City of Iowa City II r Advisory Board /Commission /Committee;��- "'� t - 1plication Form -�-� CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY C fj�D,FO�EjN V CAN DURING THAT TIME. f>!j,�,01 Advisory Board /Commission /Committee Name VGA c Cr r� Term 47Gz" Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME ✓OLD Z7WW 0,J V 6-14 HOME ADDRESS Is your home address (listed above) within the corporate limits of Iowa City? Yes No How long have you beenra resident of Iowa City? J'10 4f- P795' Gender: Male Female OCCUPATION �0'd7��S�� EMPLOYER 4141Wd,(4' �F, 1r1�4 PHONE NUMBER: HOME BUSINESS :XPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU .FOR THIS POSITION: a wueT M Vnl IR DDIMMIT LIAInWI Fnr_G n= Tu1C An\ /ICnRV RnARn7 r/EP� �% / ✓f"L arr�! G'�?/I/� to �rih� /JS/ `v P/'D�O�- J ... � : �� �.�' AT CONTRIBUTIONS CAN YOU MAKE TO THIS r4ff�ls� >7� �ec6yi, 7rePiu , LIST POTENTIAL CONFLICTS OF INTEREST: See ,� eo, d �W e o ieo ✓ FOR D 1 for information reparding Conflict of Inte '�'v�•4/ r /•� Idrl�' a'iu %L IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ZYes n No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes FNo (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 o answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2 of 9 1 r 1 ' 311 &V x ,. ,,,r, . ffo i6a BOARD, COMMISSION, & COMMITTEES - •+c.a� BUSINESS LISTING CITY OF IOWA CITY Name of City - / Board /Commission /Committee tt�>o Date 4V1,V1,k Name -1 OE SOW I lV �— Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS M NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in ap ad itional busi ss. Signature v�' , Zoe Address Misrepresentations on this application will constitute just cause for removal of an appointee. you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) OPTIONAL: PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. Age 4-* i Gender 6Q% t Income (see table) Sexual Orientation F-1 Other (Please explain below) tV� .4 eligion *0,4 Disability r /C- ace, color ethnic group �fJ National origin Human Rights Commission Application January 2012 page 4 of 9 BIOGRAPHICAL SKETCH r'> Provide the following information for the key personnel and other significant contributors in the order Iisted"ou'Fonn PagP2. Follow this format for each person. DO NOT EXCEED FOUR PAGES. -- NAME POSITION TITLE Joe Dan Coulter Professor eRA COMMONS USER NAME jcoulter - EDUCATION /TRAINING (Begin with baccalaureate or other initial professional education, such as-nursing, and include postdoctoral trainin . INSTITUTION AND LOCATION DEGREE YEAR(S) FIELD OF.STUDY (if applicable) University of Oklahoma, Norman B. A. 1966 Psychology University of Oklahoma Medical. Center. Oklahoma City Ph.D. 1971 Biological Psychology University of Texas Medical Branch, Galveston Post -doe 1971 Neurophysiology Universita di Pisa, Pisa, Italia Post -doc 1973 Neurophysiology University of Edinburgh, Edinburgh, Scotland Post -doc 1974 Neurophysiology A. Personal Statement Dr. Coulter is an enrolled member of the Citizen Potawatomi Nation of Oklahoma (federally recognized) and is active in the American Indian Science and Engineering Society, National Indian Education Association, National Institute for Native Leadership in Higher Education, the American Indian and Alaskan Native Professors, the Society for Chicanos and Native Americans in Science, the Native Research Network, +he American Indian, Alaskan Native, Native Hawaiian Caucus of the American Public Health Association and .he American Indian Higher Education Consortium (tribal colleges). Dr. Coulter is also a member of the External Advisory Committee of the Montana State University (MSU) Idea Networks for Biornedical Research Excellence program, an NIH funded program to improve biomedical infrastructure for Montana's higher education system, and 7 tribal colleges. For MSU, he also serves on the External Advisory Committees of the NIH supported American Indians into Research Program, the Center for Native Health Partnerships supported by the NIH NCMHD and the NIH supported Culturally Connected Community Goals program. He is also a former member of the External Advisory Committee of the NIH RISE program, a collaboration between Haskell Indian Nations University and the University of Kansas. In 2008 he was appointed to the External Advisory Committee of the Northern Plains Tribal Epidemiology Center/Native Americans Research Centers for Health program of the Aberdeen Area (Great Plains) Tribal Chairman's Health Board. From 2004 to 2009, Dr. Coulter served on the Association of Schools of Public Health (ASPH) Diversity Committee, and is currently a member of the ASPH /AAMC Committee Expert Panel on Cultural Competence and the ASPH - Indian Health Service Taskforce. Dr. Coulter also serves as faculty advisor to American Indian and Alaskan Native students on campus and in 1989 helped establish and directed the Life Sciences Comprehensive Enrichment Program for pre - college American Indian /Alaskan Native students at The University of Iowa. In 1998, he assisted in the establishment of the Iowa First Nations program that provides resident tuition status for members of American Indian Tribes/Nations historically linked to the State of Iowa. Since joining the College of Public Health, Dr. Coulter teaches, conducts seminars, and makes public presentations /trainings on racial /ethnic health disparities and development of cultural competence, and organizing cornrnunity -based participatory health programs, in particular regarding American Indians /Alaskan Native populations. He is also an advisor to the Historical Preservation Project of the Meskwaki Nation of Iowa, served on the Iowa Governor's Equal Employment Opportunities Task Force from 1997 -1999, and served two 4 year terms on the Iowa Advisory Committee of the United States Commission on Civil Rights. In 2008, Dr. Coulter was .ppointed by Iowa Governor Chet Culver to the Iowa Commission of Native American Affairs where he has been elected to serve as the Liaison to the Iowa Department of Public Health. In 2010, Dr. Coulter was again PHS 398/2590 (Rev. 06/09) Page _L Biographical Sketch Format Page appointed to the Iowa Advisory Committee to the U.S. Commission on Civil Rights. In 2011, he was appointed to the Governance Board of the Regional Health Equity Council of the National Partnership for Action (NAP) End Health Disparities of the U.S. Department of Health and Human Services, Office of Minority Affairs. B. Positions 1975 -78 Assistant Professor, Department of Physiology & Biophysics and Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch, Galveston, Texas 1975 -85 Member, Marine Biomedical Institute, Galveston, Texas 1978 -84 Associate Professor, Department of Physiology & Biophysics and Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch 1980 -81 Associate Program Director, Behavioral & Neural Sciences Division, National Science Foundation, Washington, D.C. 1983 -85 Assistant, Office of the Associate Dean for Community Affairs, University of Texas Medical Branch 1984 -85 Professor, Department of Physiology & Biophysics and Department of Psychiatry & Behavioral Sciences, University of Texas Medical Branch 1985 -92 Head, Department of Anatomy, College of Medicine, University of Iowa, Iowa City, Iowa 1988 -96 Chair, Neuroscience Graduate Program, Graduate College, University of Iowa 1996 -99 Interim Associate Provost for Diversity and Director, Opportunity at Iowa, Office of the Provost, University of Iowa 1999 -04 Associate Provost for Diversity and Director, Opportunity at Iowa, Office of the Provost, University of Iowa 1985- Professor, Department of Anatomy and Cell Biology, College of Medicine, University of Iowa 1985- Professor, Neuroscience Graduate Program, Graduate College, University of Iowa 1993 -04 Coordinator /Liaison, American Indians & Alaskan Natives. Opportunity at Iowa, Office of the Provost, University of Iowa 1994- Participating Faculty, American Indian and Native Studies Program, College of Liberal Arts and Sciences, University of Iowa - 2004 -08 Associate Dean for Diversity, College of Public Health, University ^ -ofJowa 2004- Professor, Community and Behavioral Health, College of Public Health, Universi_trof Iowa Honors (Selected) 1996- Association of American Medical Colleges Elected C)ffcei /_Distinguished Service-Meinbdt' 1999 -04 Explorations in Biomedicine: Native American Faculty Scientist Issues In Science Education and Research, American Physiological Society, Montana State University 2001- Association of Neuroscience Departments and Elected Officer /Distinguished Programs Service Member Federal Review /Advisory Committees: (Selected since 2000 from a total of 25 since 1980) 1999 -2004 Member, Research Centers in Minority Institutions Review Committee, National Center for Research Resources, NIH 2001, 2002 Member, Special Emphasis Panel, Biomedical Research Infrastructure Network, National Center for Research Resources, NIH 2002 Member, Special Emphasis Panel, Centers of Biomedical Research Excellence, National Center for Research Resources, NIH 2002 -2004 Chair, Research Centers in Minority Institutions Review Committee, National Center PHS 398/2590 (Rev. 06/09) Page Biographical Sketch Format Page for Research Resources, NIH 2003, 2004 Chair, Special Emphasis Panel, Centers of Biomedical Research Excellence, National Center for Research Resources, NIH 2003 Member, Special Emphasis Panel, Pre - doctoral Awards for Minority Students and Students with Disabilities, NIH Center for Scientific Review 2004 Member, Committee of Visitors, evaluation of Tribal Colleges and Universities Program, National Science Foundation 2005 Member (Ad hoc) Research Centers in Minority Institutions Review Committee, National Center for Research Resources 2005 Member, Broadening Participation in Computing Review Panel, National Science Foundation 2006 Member, Special Emphasis Panel, Pre - doctoral Awards for Minority Students and Students with Disabilities, NIH Center for Scientific Review 2008 Member, Special Emphasis Panel, Clinical and Translational Science Awards, National Center for Research Resources, NIH 2008 Member, Research Centers in Minority Institutions and IDeA Review Committee, National Center for Research Resources, NIH 2009 Member, Community -Based Participatory Research, Panel 2, National Centers for Minority Health and Health Disparities, NIH 2012 Member, Healthcare Safety and Quality Improvement Research (HSQR) Study Section, Agency for Healthcare Research and Quality C. Selected peer- reviewed publications from a total of 79 (in chronological order): Gwyn, D.G., Ritchie, T.C. and Coulter, J.D. 1985. The central distribution of vagal catecholaminergic neurons which project into the abdomen in the rat. Brain Res., 328:139 -144. Fabian, R.H. and Coulter, J.D. Transneuronal transport of lectins. 1985. Brain Res., 344:41 -48. Ritchie, T.C., Fabian, R.H. and Coulter, J.D. 1985. Axonal transport of antibodies to subcellular and protein fractions of rat brain. Brain Res., 343:252 -261. Ritchie, T.C., Fabian, R.H., Choate, J.V.A. and Coulter, J.D. 1986. Axonal transport of monoclonal antibodies. J. Neurosci., 6:1177 -11 Ritchie, T.C., Thomas, M.A. and Coulter, J.D. 1989. A nerve terminal protein with a selective distribution in spinal cord and brain. J. Neurosci., 9:2697 -2709. Cabalka, L.M., Ritchie, T.C. and Coulter, J.D. 1990. Immunolocalization and quantitation of a novel nerve terminal protein in spinal cord development. J. Comp. Neurol., 295:83 -91:, Wright, D.J., Ritchie, T.C. and Coulter, J.D. 1991. Distribution and developmental expression of the nerve terminal protein NT75 in rat cerebellum. J. Comp. Neurol., 304 53y0=545 _ v Kanekar, S. S., Ritchie, T. C. and Coulter, J. D. 1993 Spinal cord afferent system s containingt1L nerve terminal protein NT75. J Comp. Neurol., 332:198 -212. _ Selected Invited Talks/Presentations from a total of 51 (since 1997): t Making a Difference: Culture, Science and Community. Banquet Presentation. N1GMS Na' tional—, Minority Research Symposium, New Orleans, Louisiana. October, 1997: Achieving Racial /Ethnic Diversity in Biomedical /Behavioral /Social Science Research. Panel 1. Progress in Recruiting, Retaining, and Graduating Underrepresented Minorities on Regular NRSA Institutional Training Grants. Panel 2. Panelist and Presenter. National Institute of Mental Health Workshop on Minority Training Programs. Washington, D. C., October 1999. Inextricable Links: The Convergence of Diversity and Academics in Higher Education. Panel Presenter. The College Board Midwestern Regional Meeting, Chicago, Illinois, September, 2001 Community -Based Participatory Research with Tribal Communities. Featured Presentation. Montana INBRE Research Conference, Red Lodge, Montana. September 2005. Healthy Smiles Study: Community-Based Participatory Research on Oral Health of Northern Plains Indian Children Presentation, Blackfeet Community College, Browning, Montana, July, 2008 PHS 398/2590 (Rev. 06/09) Page _, Biographical Sketch Format Page D. Research Support Ongoing Research Support RFA -MD -05 -004 (Lefthand) 10/01/08- 09/30/12 NIH/NCMHD Building Research Infrastructure for the Crow Community (BRICC). The NIH Research Infrastructure in Minority Institutions (RIMI) program at Little Big Horn College builds on the campus commitment to the professional, vocational and personal development of Crow Indian students in both higher education and the workplace in the health sciences and research. Role: Principal Investigator on sub - award /Consultant for evaluation. Completed Research Support (since 2004) Cooperative Agreement IU48DP001902 -01 (Nothwehr /Parker) 03/01/11 - 02/28/12 CDC/National Center for Chronic Disease Prevention and Health Promotion University of Iowa Prevention Research Center for Rural Health. The focus of the PRC -RH is to improve the health of rural communities in Iowa and the Midwest through participatory research. The research themes are nutrition, physical activity, and aging. These are strongly in line with the health priorities identified by state and local entities. The PRC -RH uses a logic model which describes the activities and related outcomes of the PRC -RH consistent with the national CDC Prevention Research Center Program logic model. Role: Co- Investigator. 1 R24 MD001658 -01 (Robertson /Jaiyeola) 9/30/2005- 6/30/2010 NIH/NCMHD Using CBPR to Improve Oral Health in Northern Plains Indian Children. The overall objective is to plan and develop appropriate interventions to improve oral health in Northern Plains (South Dakota) Indian Children using a community based participatory research (CBPR) approach. Role: Principal Investigator on sub - award. U90/CCU724262-01 (Atchison) 09/61/2.004- 68/3112009 CDC _ Upper Midwest Center for Public Health Preparedness. The Center's objective is training of the public health workforce, including tribal _healttt_]personriel and emergency responders, to respond to bioterrorism and other public health emergencies.. ' Role: Co- Investigator for tribal preparedness (2004 - 2008). - - 1 R13 HS016435 -01 (Osterberg) 06/01/2006- 05/31/2007 Agency for Health Care Research and Quality Asthma Education Conference for Tribal Health Officers Serving the Aberdeen Area. The project conducted a regional conference on asthma designed to inform representatives of Northern Plains tribal health agencies about the current state of knowledge, research and treatment of asthma, its potential environmental triggers, prevention strategies, and environmental improvement measures. Role: Co- Investigator. RFA -RM -07 -002 (Hunninghake /Rosenthal) 09/01/2007-08/31/2010 NIH/NCRR University of Iowa Clinical and Translational Science Program. For the Community Engagement component, establishing working relations in clinical research in partnership with Federally Qualified Community Health Centers has been a priority, including developing qualifications for Federal Wide Assurances, training in human subjects' research, HIPPA, and Institutional Review Boards approvals. Role: Co- Investigator for Community Engagement. PHS 398/2590 (Rev. 06/09) Page —1 Biographical Sketch Format Page City of Iowa City r 1 Advisory Board /Commission /Committee�,,,,,�' ww®w�' A�alication Form CITY OF OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Human Rights Commission Term Ending 1/2014 Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Megan Schwalm HOME ADDRESS 914 Iowa Ave., #1, Iowa City Is your home address (listed above) within the corporate limits of Iowa City? 0✓ Yes No How long have you been a resident of Iowa City? 1 year Gender: Male Female ❑✓ OCCUPATION program Coordinator EMPLOYER women's Resource and Action center, u of Iowa PHONE NUMBER: HOME 319- 936 -8656 BUSINESS X19- ��ri -14fiR EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFYYOU FOR THIS POSITION: 11 ; a plethora of program planning experience, ranging for small scale events like film screenings /discussions to large scale community rallies of several thousand people. For my job, I coordinate a week -long, residential leadership institute and a variety of educational and engagement activities on campus and in the community. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I have spoken with Stefanie Bowers and other members of the Commission and understand that the focus of the Commission is planning community events relating to the elimination of intergroup tensions. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? I have experience working on social justice issues and am committed to eliminating tensions in our community. I have an extensive history planning and organizing community -based activities. I want to get involved in local politics and believe that this commission is the perfect fit for me because of my experience in social justic work and program planning. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest None IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 0✓ Yes R No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes r7No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application January 2012 Page 2 of 9 � r �;% BOARD, COMMISSION, & COMMITTEES - ,•ti,,� BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee Human Rights Commission Date 06/10/2012 Name Megan Schwalm Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME I BUSINESS ADDRESS INA NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an. additional business. Signature Address 914 Iowa Ave. #1, Iowa City, IA 52240 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. Human Rights Commission Application January 2012 Page 3 of 9 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) nPTInKIALL PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 32 Age Women Gender 2 Income (see table) Heterosexual Sexual Orientation Other (Please explain below) parent of a child of color. Human Rights Commission Application January 2012 page 4 of 9 NA Religion None Disability White Race, color or ethnic group US National origin City of Iowa City r 1 Advisory Board /Commission /Committee t NZ. ' "�' `application Form -�-� 7W CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT -TIME. Advisory Board /Commission /Committee Name Human Rights Commission Youth Advisory Commission (shall not be more than 18 years of age at the tirrre:;of app icati0p Name of Iowa City High School or high school equivalent: Signature of parent/guardian: ' NAME Dan Tallon HOME ADDRESS 706 E Market Is your home address (listed above) within the corporate limits of Iowa City? 0✓ Yes F-1 No How long have you been a resident of Iowa City? 5 years Gender: Male 7 Female OCCUPATION snldierl student EMPLOYER Iowa Army National Guard PHONE NUMBER: HOME 319 5418204 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: ' -owing up with a gay father and a gay brother exposed me, at a young age, to those that disliked my family :cause they did not understand or because they thought my family was somehow wrong. This has led me to a life of advocating on behalf of those who might be discriminated upon for any reason. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I understand that the educates the public about discrimination and reccomands courses of action about how to stop future discrimination. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORAPPLYING ? I would like to serve on this commision and provide my time in the hope of stopping future discrimination, discovering current institutionalized discrimination, and educating residents about the resources available to them if they have experienced discrimination. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest none. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? F] Yes 0✓ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? F]Yes QNo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application June 2012 Page 2 of 8 BOARD, COMMISSION, & COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Human Rights Commison Name Dan Tallon � r r 0 �®n%I, RK, CITY OF IOWA CITY Date 07/18/2012 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 8). List all businesses in which you or your spouse /domestic partner have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS none r .> Y °a ... -� - • w. it NOTE Signature A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Address 706 E Market Iowa City, Iowa Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. Human Rights Commission Application June 2012 Page 3 of 8 TABLE OF INCOME GUIDELINES AND DEFINITIONS FOR IOWA CITY Effective February 9, 2012 Household Size 30% Median Income (Poverty Level) 50% Median Income 60% Median Income 80% Median Income (low income) Median Income 1 $16,900 $28,150 $33,780 $45,000 $56,300 2 19,300 32,150 38,850 51,400 64,300 3 21,700 36,150 43,380 57,850 72,300 4 24,100 40,150 48,180 64,250 80,300 5 26,050 43,400 52,080 69,400 86,800 6 28,000 46,600 55,920 74,550 93,200 7 29,900 49,800 59,760 79,700 99,600 8 31,850 53,000 63,600 84,850 106,000 ATTACHMENT TO APPLICATION FOR THE HUMAN RIGHTS COMMISSION It is the mission of the Iowa City Human Rights Commission to protect residents of the city from discrimination as defined in the Human Rights Ordinance. In order to further this goal, the city strives to ensure that the Human Rights Commission is representative of the community. Therefore, "appointments shall take into consideration men and women of various racial, religious, cultural, social and economic groups in the city." (Ord. 94 -3647, 11 -8 -94) OPTIONAL PLEASE PROVIDE ADDITIONAL INFORMATION FOR THE COUNCIL TO CONSIDER WHEN CHOOSING AN APPLICANT. 23 Age male Gender poverty Income (see table) straight Sexual Orientation F-1 Other (Please explain below) Christian Religion Inone -] Disability White Race, color or ethnic group National origin Human Rights Commission Application June 2012 *N'*"*"�� page 4 of 8 NOTICE 17i THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: POLICE CITIZENS' REVIEW BOARD One Vacancy — Four -Year Term September 1, 2012 — September 1, 2016 Duties of the Police Citizens' Review Board include reviewing Police Department investigations into allegations of misconduct lodged against police officers, conducting further investigation of the complaint when the Board deems it necessary, and issuing a public report which explains why and the extent to which the complaint is sustained or not sustained; maintaining a central registry of complaints against sworn police officers and issuing annual reports regarding the disposition of the complaints to the City Council; reviewing police policies and practices from time -to -time and recommending changes to the City Council when the Board deems it appropriate. Iowa City appointed members of boards and commissions must be eligible electors of the City of Iowa City. However, the City Council reserves the right to waive the residency requirement for good cause shown. The City Council also reserves the right, for good cause shown, to waive the requirement that the Board include one current or former "peace officer" as that term is defined by State law. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. 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 Police Citizens' Review Board should be directed to Marian Karr or Kellie Tuttle at 356 -5041. 7/12/2012 7�OX y "S fD ►-3 y CrJ fD d eD z d or A N b r FBI n C r yC X yC �C >C o N H+ A N i ►-3 y CrJ fD d eD z d or A N b r FBI n C r 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: 3 Females: Council Announcement Date: May 15, 2012; July 10, 2012 Application Deadline: Wednesday, 5:00 p.m., July 25, 2012 Council Appointment Date: July 31, 2012 After 08/13/2012 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. ** Appointments to the Board shall include one current or former "peace officer" as that term is defined by State law. The City Council reserves the right, for good cause shown, to waive the requirement that the Board include one current or former peace officer. ** The City Council also reserves the right to waive the residency requirement for good cause shown. POLICE CITIZENS' REVIEW BOARD One Vacancy — Four Year Term September 1, 2012 — September 1, 2016 Term expires for Royceann Porter Gender Balance Requirement: 1 Female (M) Mike McKay M 1105 Keokuk St (F) Royceann Porter rx-1 136 Appanoose Ct (M) Dan Tallon M 706 E Market 0 Denotes applicant completed the Confidential page of the application. City of Iowa City _ r Advisory Board /Commission /Committee!'~ Application Form TO CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Citizens Police Review Board Term 2012 -2016 r - -_> Youth Advisory Commission (shall not be more than 18 years of age at the_ --Umg of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME Mike McKay HOME ADDRESS 1105 Keokuk St-., Is your home address (listed above) within the corporate limits of Iowa City? 0 Yes 7 No How long have you been a resident of Iowa City? 23 Years Gender: Male R Female OCCUPATION Owner /Officer EMPLOYER Keystone ITS Inc. PHONE NUMBER: HOME 319- 337 -6185 BUSINESS �1A_�a�_AatA EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: While in charge of administration at Systems Unlimited, I was in charge of all internal investigations regarding child at ldult abuse claims and corporate policy infractions. I then decided the appropriate courses of action. While perrorming this function I learned the importance of gathering information, sorting out facts, cross checking, etc. I am a follower of current events in the area and am interested in seeing that Iowa City is a great(er) place to live. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I know when and why it was founded. I know that it is a board for citizens to approach with unresolved issues regarding treatment by the force or perceived unfair policies and practices of the force. I know that it has no direct power, but is a good communication vehicle for the citizenry as well as the police force. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? I think that my years of experience in positions where I interacted with the powerful and the powerless has given me a good basis for this advisory board. I have served on juries and thus have seen that process in action. I also recently served as the Chair of the Housing and Community Development Commission which gave me insights into some of the tools the city has to improve the lives of the citizens. I would draw on all of this as a member. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest I resigned form the HCDC because of potential conflicts of interests between my computer business and the recipients of city funds for IT projects. I do not see the possibility of a conflict with this board. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 0✓ Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes ✓QNo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) tisrepresentations 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 January 2012 Page 2 of 8 BOARD, COMMISSION AND COMMITTEES►�`1 °� BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee Citizens Police Review Board Date 05/30/2012 Name M -� Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS Keystone IT, Inc. 365 E.College St. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature �,,u Signature of parent/guardian (Youth AdvisoryComion only): Address S/-7 � ,A-- 47-,, Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail answer all the questions, Council may not consider your application. General Application January 2012 Page 3 of 8 City of Iowa City _J r 1 Advisory Board /Commission /Committee A uk IN /I replication Form -ft-&A -- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. r �q Advisory Board /Commission /Committee Name LCe �-t, 2-e4q- &ell-' UOCUd Term ZN2 -%2—'oI(o Youth Advisory Commission (shall not be more than 18 years of age at the time of application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: NAME kow&ad yn. e"ej- HOMEADDRESS Is your home address (listed above) within the corporate limits of Iowa City? a es No How long have you been a resident of Iowa City? f Gender: Male F] Female OCCUPATION TapL\�1_ �/ C V- EMPLOYER �f-< C' S ,— l PHONE NUMBER: HOME (l UL 2,-Sq° �' z- BUSINESS CSIA y2.i,° 2-4-49 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: � �f' q.� tai- rz,�-�' -�-e- w�.�- w�.� -�- � � w.�•�..�u.,�..�( -�' 1...�aC.�2,r� �c.�t.- sics,.� _ t)J iL -c%I,. c� LJL tom. ✓w'�j`e 3 t +n Lv, ec) cc i,. l WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? �-U1— 1Q�,- v..R�(. �li_C�.� S � ,`���.�S G°3(� •fG,,.Q_ l��cz.��: :.a ��-., WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? �� St- ..�.v c�..erv�[e i.�►- �.'•!- -(,..Y Gc3an✓�.�:u.� —�, i� � �-- �,1��� � -�v �a(�`�� LIST POTENTIAL CONFLICTS OF INTEREST: See naae 1 for information reaardina Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes 0 (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 o answer all the questions, Council may not consider your application. General Application January 2012 Page 2 of 8 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City ?CKS Board /CQmmission /Committ� Name% -1� I �_.:. ®� - %mum CITY OF IOWA CITY Date ©(P Z/ Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NOTE: A new form ust be comp) t if the above information changes or an ownership interest is acquired in an addi io al business Applicant Signature Signature of parent/guardian (Youth Advisory Commission only): Address Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application January 2012 Page 3 of 8 City of Iowa City _ r Advisory Board /Commission /Committee;' =0 application Form --- CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board /Commission /Committee Name Police Citizen Review Term Youth Advisory Commission (shall not be more than 18 years of age at the tir 147 f application) Name of Iowa City High School or high school equivalent: Signature of parent/guardian: - NAME Dan Tallon HOME ADDRESS 706 E Market Is your home address (listed above) within the corporate limits of Iowa City? 0✓ Yes F-1 No How long have you been a resident of Iowa City? 5 years Gender: Male 0✓ Female F] OCCUPATION Soldier/ Student EMPLOYER Iowa Army National Guard PHONE NUMBER: HOME 319 541 8204 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 'lave served for 6 years in a military unit and understand that those who have been trusted with power must use . t power effectively and fairly. I am very interested in the proper application of the law and ensuring that a balance between citizens and the police is kept. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I understand that the board investigates claims of police misconduct and makes recommandations. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORAPPLYING ? I can contribute my time, my fair judgement, and my experience as a resident of Iowa City to the board. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest none IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? R Yes R✓ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes 7No (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 June 2012 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Police Citizen Review Name Dan Tallon � r j CITY OF IOWA CITY Date Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, your spouse /domestic partner, or parent if Youth Advisory Commission applicant, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature Signature of parent/guardian (Youth Advisory Commission only): Address 706 E Market 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 June 2012 Page 3 of 7 17j NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: YOUTH ADVISORY COMMISSION One Vacancy - Two -Year Term January 1, 2011 - December 31, 2012 One (1) person — Tate High The mission of the Youth Advisory Commission is to promote understanding and awareness of Iowa City among Iowa City youth, allow a select group of youth to help make decisions concerning them and their peers, enable youth members to utilize and expand on their leadership abilities, to serve as a mechanism for communication between youth and adults in Iowa City and create a bridge whereon youth and adults can develop partnerships. Membership shall consist of seven [7] members appointed by the City Council currently enrolled in an Iowa City high school or high school equivalent. Four members shall represent City, Regina, Tate, and West high schools. The three remaining members shall be at large. All ages shall be calculated on the date of the filing of applications, and shall not be more than 18 years of age at the time of application. All members shall be residents of Iowa City. Applications must be received by 5:00 p.m., Wednesday, July 25, 2012. 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.icqov.org. 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: 3 Females: 2 Council Announcement Date: October 26, 2010; December 7, 2010; January 10, 2011; February 15, 2011; March 22, 2011; May 3, 2011; June 7, 2011; August 2, 2011; September 6, 2011; October 4, 2011; November 1, 2011; December 6, 2012; January 24, 2012; February 21, 2012; March 20, 2012; April 17, 2012; June 5, 2012 Application Deadline: Wednesday, 5:OOp.m., July 25, 2012 Council Appointment Date: July 31, 2012 (Recommendations to be made by Council liaison) After 01/24/11 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. YOUTH ADVISORY COMMISSION One Vacancy — Two Year Term January 1, 2011 — December 31, 2012 One (1) person — Tate High Gender Balance Requirement: None No applications as of Wednesday, 5:OOp.m., July 25, 2012 El Denotes applicant completed the Confidential page of the application.