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HomeMy WebLinkAbout2014-04-01 AppointmentsIla NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: AD HOC SENIOR SERVICES COMMITTEE Six Vacancies — to fill terms beginning May 1, 2014 — December 1, 2014 The duties of the Commission are: 1) evaluate the current vision, mission, programming, and recent accomplishments of the Senior Center, as detailed in the 2013 Annual Report; and to review the current demographics of the participants served by existing operations. 2) make recommendations to the City Council on how Iowa City should use current financial and physical resources to meet the needs of the Iowa City seniors. 3) identify any obstacles, including facility considerations, which may be hindering the City's ability to serve the senior population and to make recommendations that would minimize or eliminate such obstacles. The Senior Services Committee shall submit a written report to the City Council by December 12, 2014. Absent further action by the City Council, the Diversity Committee will dissolve on December 12, 2014. The Ad Hoc Senior Services Committee shall determine the frequency and conduct of its meetings. Applications must be received by 5:00 p.m., Wednesday, March 26, 2014. 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 Senior Services 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 Females: 0 Council Announcement Date: February 18, 2014 Application Deadline: Wednesday, 5:00 p.m., March 26, 2014 Council Appointment Date: April 1, 2014 After 05/19/2014 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AD HOC SENIOR SERVICES COMMITTEE Gender Balance Requirement: 3 Male, 3 Female Six Vacancies — to fill a term from May 1, 2014 — December 1, 2014 Residents (At least one Senior Center Commission member# and one non - member of the Senior Center *) (M) Jay H. Honohan 0 (M) Donald Friedman 0 1519 Somerset Ln 915 Dearborn St (M) Barry Bender 0 (M) Hiram Richard Webber* 0 812 Dearborn St. 320 E Wasington, Apt 7 -H (F) Karin Franklin* 0 (F) Ellen Cannon 0 816 Sugar Loaf Circle 320 E Wasington, Apt 6E (F) Kathy Mitchell 0 (F) Naomi Novick El 722 Iowa Ave. 1313 Santa Fe Dr. (M) Hodge M. Carter* 0 (M) Helmut Schrott D 1771 Mackinaw Dr 3117 Alpine Ct (F) Mary Ann Miller D (M) Joe Younker* I] 1131 Fairchild St. 1011 6th Ave (F) Mercedes Bern -Klug El (F) Louise Young I] 1803 C. St. 320 E Washington, Apt 9D (F) Mary Gravitt 0 (F) Jane Dohrmann* 0 2714 Wayne Ave 337 Ferson Ave 1XI Denotes applicant completed the Confidential page of the application. Page 1 of 2 Non - Residents (Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise not available from applicants who reside in Iowa City.) (F) June Braverman* 0 349 Koser Ave University Heights, IA (F) Charlotte Walker* 0 1799 5th Ave Coralville, IA (F) Eve Casserly* 0 1615 Pine Ridge Court Coralville, IA (M) Jeff Kellbach* Fx_1 380 Locust Dr North Liberty, IA (F) Erin Linn Robinson* Fx1 809 20th Ave Coralville, IA 0 Denotes applicant completed the Confidential page of the application. Page 2 of 2 City of Iowa City Advisory Board /Commission /Committee �;�r►',� pplication Form AWMI IT E5 CITtOF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND D BU D F�HE PUBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATIWMLL�BE C ®NSIDERED FOR THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DUR4 HAT„TIMErn c= ,-a : Advisory Board /Commission /Committee Name Ad Hoc Senior Services Committee ThRn NAME Jay H. Honohan HOME ADDRESS 1510 Somerset In, Iowa City, IA 52240 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? 54 years Gender: Male a Female OCCUPATION Attorney EMPLOYER Self employed PHONE NUMBER: HOME (319) 338 -6990 BUSINESS (319) 351 -8100 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFYYOU FOR THIS POSITION- center L;ommission Chair, Developed the Senior Center Foundation and current President of Friends of active praticipant Senior Center classes and clubs, Volunteer lawyer at the Senior Center for 15 years, :er senior center member award for 2013, A member of the target population of Seniors who receive the �s in Iowa City which the committee is to review. Extensive experience serving seniors as clients in law of 54 years. Previous served as Iowa City Police Judge, City Attorney Iowa City, St. Marks Church Board, Way Board, Chamber City Relations Committee, Two ad hoc City Manager Committees Iowa Citv. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Since this is a brand new committee the only information that I have is that contained in the resolution establishing the committee. It's target is to review the delivery of services to seniors in Iowa City and explore the diversity of Seniors receiving services and report its findings to the City Council in December of 2014, It consists of seven members, one council person, one member of the Senior Center Commission, on participant of the Senior Center and four other members. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING ? First as a member of the target population, I have experiences similar to other seniors in the community as to health and senior concerns. Second, my experience as a participant, commission member, and a senior citizen allows me to have a perspective that individuals who do not have that background do not have. Finally, people who know me ,ecognize that I put in maximum effort in any endevor I am involved in. i 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 D No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? W]Yes r-�No (It has been Council policy not to permit an individual to serve on two Boards or Commiccinnc at +ho COH,� +;__ I ?Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING � r e �AW - %Ago_ CITY OF IOWA CITY Name of City Board /Commission /Committee Ad Hoc Senior Services Committee Date 02/24/2014 Name Jay H. Honohan Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS Atlasta Farm Trust (family farm trust 50% interest) 330 E. Court, Iowa City, Iowa 52240 Justa Farm Trust (family farm trust 50% interest) 330 E. Court, Iowa City, Iowa 52240 Old Feed Store (office rental 10% interest) 330 E. Court, Iowa City, Iowa 52240 Note I am no longer an owner of the law firm of Honohan, Epley, Braddock & Brenneman having retired in 1997, 1 am currently of counsel to the firm 0 ze -� c� ! if NOTE: A new form must be completed if the above information changes or an o Mrsk *p int $t is acquired in an additional business. )> cn t-N . - A /1 Applicant Signature. Address 1510 Somersea, Iowa City, IA 52240 Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail Ito answer all the questions, Council may not consider your application. General Application January 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER 0 Senior Center Member Senior Center Commission Member ❑ Non - Resident (Address: ❑ Other (Please explain below) o o -�- February 2014 rn February 2014 IMisrepresentations 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 e%^A. �0 - -F '7 ATTACHMENT TO.APPLICATION FOR THE AD'HOC SE MOR SERVICES COMMITTEE; The Senior Service Committee sha I consist of seven (7)' members to .be' appointed.— ' by the City Council. Members of other City boards and commissions may serve on'' the Senior Services Committee. Mgmbership shall. include at least one member of the City Council; Senior Center C0M", Mission and anon- `member of the Senior Center: ; Up to two non-residents of,the City iof Iowa City shall be eligible tb serve on the:;' committee if they are' residents of Johnson County and offer desirable expe. rtise z� `- available from applicants who resid,'e in lowa' City . CHECK ALL THAT APPLY FOR `COUNCIL fO CONSIDER WHEN CHOOSING A MEMBER Senior Center Member, 31 , a I Senior Center Commissiin Member.: Non- Resident (Address . El .Other (Please'explain below) f i o i ZEn -*� m a i. I February 2014 is ' City of Iowa City r 1 Advisory Board /Commission /Committee 1 Ill IR—Aw . rMr ®r�i 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. Advisory Board /Commission/Committee Name Ad Hoc Senior Services Committee Term 06- 12/2014 NAME Karin Franklin HOME ADDRESS 816 Sugar Loaf Circle Is your home address (listed above) within the corporate limits of Iowa City? Q Yes R No How long have you been a resident of Iowa City? 40 years Gender: Male[] FemaleQ OCCUPATION Retired EMPLOYER NIA ,. PHONE NUMBER: HOME 321 -8261; kadnf @q.com BUSINESS N/A EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Served on the Johnson County Livable Communities board. Current chair of the Oaknoll Retirement Residence board. 27 years of experience in the public sector, with 16 as a department director dealing with budget & resource allocation issues. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? understand this committee is charged with evaluating the current services provided by the Senior Center, paying articular attention to the demographics of those served and not served; making recommendations to the City :ouncil as to the best use of resources available to serve Iowa City's seniors; and to identify any obstacles to optimal WHAT MAKE TO FOR Given my work experience, 1 understand the need to be fiscally responsible with limited resources and yet provide the highest level of efficient public service possible. My work with Livable Communities gave me numerous insights into what is needed for seniors to thrive & continue to enrich the community. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information reglarding ConflicLof Inteftt None c-) -n IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ✓( Yes N tp DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSe Y s F�No (It has been Council policy not to permit an individual to serve on two Boards or Commissio_& at thee,,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 January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Ad Hoc Senior Services Committee Name Karin Franklin CITY OF IOWA CITY Date 02/25/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NONE O M x. NOTE: A new form must be c acquired in an additional busi Applicant Signature, Address 816 Sugar Loaf Circle / if the above information changes or an ownership interest is Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail ito answer all the questions, Council may not consider your application. General Application January 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ❑ Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ) ❑✓ Other (Please explain below) Resident of Iowa City. Non - member of Senior Center. February 2014 c 924 -•�.. February 2014 City of Iowa City I r 1 Advisory Board /Commission /Committee '�� �'�� t A`,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 G y N IQ �iM KG, Term [III U14 AA V NAME HOME ADDRESS ZZ �OUII� � �Jz9 Is your home address (listed above) within the corporate limits of Iowa City? __71 Yes r No dd How long have you been a resident of Iowa City? �fk 11 -7a Gender: Male E] FemaleFA OCCUPATION RE12G EMPLOYER V} PHONE NUMBER: HOME 3CQ� �j3° D1hO BUSINESS - -3 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSt°GI94V: -- -.7m Ea y� arTkcOW T IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? r I"#"1 T AtA (4 9 %e W to CRMR�tMKq come -11— (4 kaffp popy) Z A0 A ARPIt� of 4* *i-016 z DRAM INO �TvoVq�Aii� Imt) C?Wa W*9 4b foNs .' riom av Cov4Q& wi-ftNgs) r ovaq UN WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORAPPLYING ? qkg Ltv[__D IN kWA Wq Rg CLOX -1'b 4; 44ps, Z kwo(O Gtr Artv&yG zla� wea cfwvo M� �0 bctsD vow" Y051.6000 rtF mftq ows, f ove tuop Gl11" ' � � oa 63E aF) uvevaof vw(igos � I ftm A w Pr�Ut;�tiG; N. �ME�IC3G'� dF tit co"voaq. T uucu& flr mq �f v I L15T POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? M Yes F-1 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? 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 to answer all the questions, Council may not consider your application. 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(tC Mann i n9 F�re , Commun Devefapwn)r) , QnQ. 0�2�G�S (�e:7Cl�ighhothoaA Ccinfc�s, 5� U�tahle CornmvnLtq). u?di-X 5"C CQWMVO �5- 5(mo� Rwtma Du01a . � we vowNftKep KTAC s kljul�uu�& (WRU tr was w %e fvqe wocli pyoqvam, boaN, Z Vobv014 9 Me puvl ( k b w fk S(Wlup Cep. R rnMlon U, al✓� f�p $euwq (Ovtmla k ou�oU�h C����e Cas � a�hGSS�w hi�Q 4-11 c�aSSQS , 5efvlc2 009s, swtw miOces, �actto e�L- P�omolu� t�� of q vyq i. TT of k gw)rlq PwuD qfwp 1 fW Ufe s % es p(olec'-, tG.e Sou [u; eeni&r T�ototi CZ 6n�efvtC� ,VlW�aCeIaV4UORovlgvu)c4l P am rnan9cr eF 1� I,�h�arc� (�v�f� � Ass����� • C I alp �'�ke a lllroF c(as,es lh�'DU�h Ktf�I,t�CC( �criv�rnun�j m I�e(a� we- meet cut Cbb�2 Cenit�- Zi fufRs howeqellr, w'e 4 Sc- n�ia�S Q :-4n M BOARD COMMISSION AND COMMITTEES ' BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee 108 6c OCE-i 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, 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 MONE s- NOTE: A new form must be completed if the above information changes or an ownership interest is acqL Applicar /_rt;IT 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ImSenior Center Member © Senior Center Commission Member ❑ Non - Resident (Address: ❑ Other (Please explain below) February 2014 N C) r City of Iowa City �_.14 Advisory Board /Commission /Committee -' '' Application Form -- 10h THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTD �R TFIBLIC, WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION L BE CONSIDERED FOR 'THREE MONTHS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING HAT TIME Advisory Board /Commission /Committee Name !!55d0/0/e S�VlGgy(:14tna /Term %, G4 tom �' NAME Z Ld6ze- /Y . C.4/� r HOME ADDRESS 131-1- S.4AJ -rA / / -1 / 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? , PAt-Ir Gender: Male Female OCCUPATION ,C-i9 L- -"Ti`7 Am>�✓�sT,��TTlah/ EMPLOYER Ak/1CY Akm Y /WO PHONE NUMBER: HOME 3%9-- q-?D -3�SD BUSINESS 38 -339 399irec6 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: o 11V7•ieE5T",4n/b 4f&MM /IrX4EA1 -7re- e::�O tii/1c G(Nl7`Y - 46/•316, . del/& AS AaWFe 9 C'v - 011,41k OA/ IaWX C17 -YJr f34UE-� ( iz) WA ,APP! -/�I diii a 14SS, �rlelgU7144 - � /Owe C17Y? v:� AN6 5�R vE6 Oil �o•� M / �-� MR-11C/ WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? S A2> 110kf1 AlV D 1/lS M11 SGt�CESS'ES oFSEn/l0l� �'ENTERj /LIA����cv�.u��c/,jXX1 -a/1 7v E Cl"ryeOUA!C /L- di✓7{�GI.lE o� �1%r4 .9L �/7> /i� G ��Sou�CES To ���.�5�/rar�S �c,1E� ; �� /l��-.�/T /f"Y �'22jE.�'.1' � s"c2✓irr% spit/! �{TleAZS" -;'0 WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? ' C'iryCan/� ��/s V Fky �ffE -CTrV�Vy 1411-771 A11y9T 72f� ST r.P.o % Q �o'�a� 4� -: IVMOQ N� 'LIST POTENTIAL CONFLICTS OF INTERES - See page 4 for info mation regarding Conflict of Interest NOM %GrGD �� G�/ /LG �' //✓fl ST/zvi✓ OS /7 /I/�� aS TrIWV o /+-c.,11-i rA7`2 ,4A,l� it ©!CE" �S IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? O Yes � No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes MNo (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 4n,. 044 Page 2 of 7 ouf P/- �/tfj' �v.�ir�r�ivtri' �aL7c Y, j r � BOARD COMMISSION AND COMMITTEES � ° A zt BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee 5bwlek ��'!eylc6S 1tiMl-r7Z25" Date Name /Id ez_ Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADSRESSZ-- x• C-) NOTE: A new form must be c pieted if the above Information changes or an ownership interest is acquired in an additior ess. Applicant Signature pp g Address �3 >� Si4�✓ .9 i=E /�l�i�/� /9AIX Clrll 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall Include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER Other (Please explain below) t_-aA1 A16C A0A1 IX R� V 4Af7- ,4A1b /1V,�iz rA1(17 A.5 W� ,@ /�'li°k'v v //l/� s'�- f7�9 //i/f�tl� Gl/EGL /�E /i(/G die IlV blv /b oAZ-S- X" �f�. Co.v, m uti'/ i"i February 2014 0 Senior Center Member *n a Senior Center Commission Member -�-<M ro Non - Resident (Address : CD Other (Please explain below) t_-aA1 A16C A0A1 IX R� V 4Af7- ,4A1b /1V,�iz rA1(17 A.5 W� ,@ /�'li°k'v v //l/� s'�- f7�9 //i/f�tl� Gl/EGL /�E /i(/G die IlV blv /b oAZ-S- X" �f�. Co.v, m uti'/ i"i February 2014 City of Iowa City r Advisory Board /Commission /Committee ,lpplication 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 VACANNCCY�.,DrURING/THAT TIME. Advisory Board /Commission /Committee Name � -- A � �1 ��1 I � Term NAME "A n rn (kr HOME ADDRESS IN TaCIT� Is your home address (listed above) within the corporate limits of Iowa City? ZYes No ,52Z4 How long have you been a resident of Iowa City? Gender: Male M Femaleg OCCUPATIONII"�"�?( U �(".. EMPLOYER' On 1%, PHONE NUMBER: BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: PUMP � � I WHAT IS YOUR PRESENT KN THIS ADVISORY BOARD? WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYINGI? �, ��� ", e • s' 1 ��i �; I • .,r�,,,�/��/ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes ❑ NQ, DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OK COMMISS19N? Yes No (It has been Council policy not to permit an individual to serve on two Boards or Commissio0im th ame ti .) Misrepresentations on this application will constitute just cause for removal of ara Aoirse. If;o'u fail to answer all the questions, Council may not consider your application. -.e- General Application: January 2014 Page 2 of 7- BOARD, COMMISSION AND COMMITTEES 1ll BUSINESS LISTING,,_ CITY OF IOWA CITY Name of City A Board /Commission /Committee A ��c'� 1�11�i'-` V�CQ����i�('�1116ate� 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, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS N O r Asa NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. 'n. . . L Applicant Signatutree_/ Address I « tZ�t Z.4 5 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER e X_ Senior Center Member C-)'4 _ r— m -o M ❑ Senior Center Commission Member r`? s fv ❑ Non - Resident (Address: ) ❑ Other (Please explain below) February 2014 City of Iowa City r 1 Advisory Board /Commission /Committee "'"''''� '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 Senior Services Committee Term May -Dec 2014 NAME Mercedes Bern -Klug HOME ADDRESS 1803 C. Street 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? 10 years Gender: Male ❑ OCCUPATION Professor PHONE NUMBER: HOME 338 -3809 EMPLOYER UI BUSINESS 335 -1265 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU I-UK I hll, FUZZ I wrv: FemaleQ Researcher who specializes in needs of older adults experience Tdvanced chronic illness. Director of the UI Aging Studies Program (interdisciplinary approach to the study of older adulthood). Daughter of a 92 year old who lives in Iowa City and uses a variety of services geared toward older adults. wuw-r !e W11 iQ ol?FCFAIT KNnWI I=nnP OF THIS ADVISORY BOARD? c At the Feb. council meeting there was a decision made to look at what the City could bi@09 ta:suppplder adults living independently. --� o M WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR AP NG ? I have an understanding of the concerns that many older adults face as they get older. I have good group process skills. I am strongly committed to Iowa City being an elder - friendly place. I am familiar with the Senior Center, Elder Services Agency, Heritage Area Agency on Aging, Johnson County Livable Community Group. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest I reviewed the Senior Center questionnaire before it was distributed. I am a former Senior Center Commissioner. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? U Yes U No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? [—] Yes [Z]No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail to answer all the questions, Council may not consider your application. General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Ad Hoc Senior Services Committee Name Mercedes Bern -Klug 1 r i NOT CITY OF IOWA CITY Date 03/07/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDR S None 2) ..... . rn -t- f TI 0 NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additi Applicant Signature Address 1803 C. Street al business 4M 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR v �d1s THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall Include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER February 2014 Senior Center Member © -�- :;a F] Senior Center Commission Member r� -4 -- -q C-. M mom M ❑ Non - Resident (Address: C) CA co ❑ Other (Please explain below) February 2014 City of Iowa City r 1 Advisory Board /Commission /Committee "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 Term NAME (At 't�,(� HOME ADDRESS Is your home address (listed above) within the corporate limits of Iowa City? Yes F] No How long have you been a ropsident of Iowa City? Gender: Male 0 Female OCCUPATION jEMPLOYER PHONE NUMBER: HOME BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: (9kD 0 � n 1-I AT IC VAI ID DDCQCAIT IlAIA \A /1 C11AC AC'rU1Q A11\ /1QADV DAA Cf17 .C- I +� U1 TV WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? FYI e*"ek 0—e q— 'c-1- (2-,&1-ztE4t LIST POTENTIAL CONFLICTS OF INTEREST: See paae 1 for information reaardina Conflict of Interest k)b Ile-, IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? Yes R No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD O 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.) FMisrepresentations 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 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES �,,�••�� ���"t BUSINESS LISTING.. CITY OF IOWA CITY Name of City Board /Commission /Committee �yt-� 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, 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 0 Z E7 NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. ^ A 4 Applicant Signature, 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER r" Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ) ❑ Other (Please explain below) February 2014 r-- c') C17 N) City'of Iowa city r Advisory Board /Commission /Committee, "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 A'O We- S,dd We- SjfFA11e�-9 Gruen rk Term NAME e-RigCPmAkJ HOMEADDRESS ql< 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? YeA," Gender: Male Female OCCUPATION Rg ► /2cv GAr-Q.ei-, 9 , —,, e - x EMPLOYER PHONE NUMBER: HOME 319 — 6Z4 — 144(6 BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: fILF�SfGA L /*2>gCA RY ifif31Li �' �' 't D IJO P- A) 1-1-H QemPGi-- A C T IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? -4o R ✓I PFD f��.� �� ��-i•' �� /��,pf �� �'�� Gt �` /'s ,�&Aov- VoV"z -a m r--, WHAT CONTRIBUTIONS CAN YOU WAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? A's f+ 2 �5 r� RQL 41-bp �/�6 =1 r.)� ✓ �%?� 1 t0' t `�N +Ptt_ -::F- H av N-O vtmi �Jz u. Glfy tS s�arv.es LIST POTENTIAL CONFLICTS OF INTEREST: See paae I for information reaardina Conflict of Interest dpde . �. 4 Q) -& IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? � Yes DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD O CON „�. Yes No (It has been Council policy not to permit an individual to serve on two Boards or Commissions�3�ie same ti e.) Misrepresentations on this application will constitute just cause for removal of an "in*. If fail to answer all the questions, Council may not consider your application. , General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING -•a.a� CITY OF IOWA CITY Name of City Board /Commission /Committee AD Hbc- J;ed roe- .SeizVlc -:s Date 9 17-7- Izze Name M er rJ Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS a I r A rn y . .. GJ NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Sign M,,� Address I/ 3 9166e4j -Yr �f: JA C- 11-Y �51z- 'qb 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER PSenior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ❑ Other (Please explain below) February 2014 C.r,3 City of Iowa City Advisory Board /Commission /Committee'' ' I . ON %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 �N me U (Z2Kr e� C rj ICU Term t b�� HOME ADDRESS NAME Is E your home address (listed above) within the corporate limits of Iowa City? [01'9es No How long have you been a resident of Iowa City? tO i jaA Gender: Male Q Fernalell OCCUPATION V,,4iYA EMPLOYER PHONE NUMBER: HOME °I,� 0 —I,a sq BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: r � , r 1 � WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORfi ? Ca/U, d. t17V n Cep O/l/l r `a 4 C;:�" / .. AArzxk 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? E211es FJ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes EzNo (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 January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Name ti.r p 4, CITY OF IOWA CITY Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS N z� NOTE: A new form must acquired in an addi Applicant Signatu Address completed if the above information changes or an ownership interest is 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ❑ Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: 10 Other (Please explain below) February 2014 N C') _<r City of Iowa City I 1 Advisory Board/Commission/Committee 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 &kj2� -gw1of re CPS t�� Term NAME F % %f�l ,L. C`a�l� -Id1� HOME ADDRESS 520 Lf, ZiIa5�1>f1Q Is your home address (listed above) within the corporate limits of Iowa City? gYes r] No How long have you been a resident of Iowa City? 1971- - � .Gender: Male r Female OCCUPATION ire EMPLOYER (s) See alached &sty PHONE NUMBER: HOME 3�9- '�y-83j2 BUSINESS A9 _ © r EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS PQS610: `l1 -Pao - S "ee aftched -rwtme r=- Scamer?ycad �"ozveYS )'ev 4enf 'epyese�� = "' Imo'! roz0a 61 Y <M = N) WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Tie k),wgfyoN of Ahe,00 3�eN1oY few✓ «es C*mWee Zrras appavncr � Tyre 2-ozua C`�hy, 6-k &z wc11 M defy, 26f11 77ie cb�-e jmr po e oFfl -le- cry Vfee- �s evaf u,:Ae Ale ser✓Me 7' -seeds ofa expa�r -J??9 F a`yvW5e aq >rrq To%'u1a 90 y of -td yo jelve ;s an ddvlol adpald -10 Wre Cy zf ebzutci1- WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING ? x a�� a 5e,1 '0r, Iowa 6 13z fesidcnI zerjo &-rf sees to eolf ff-911zek hk �r�7>�s arrd a;wf iti sefliar ahxen se;y ce.S lieedl asses r-f (cuYre l ��jecfed - I-Aare wo��e� ex�es�s�'vel y zrr >�h �1�e agr�r� �� pula�ia�T �1�yazry�ou� �z/ �y�essrv�7a 1 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? ZYes FJ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes 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 to answer all the questions, Council may not consider your application. i General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING CITY OF IOWA CITY Name of City Boa rd /Commission /Committee ireyt/c (&ffm�A_le Date ` Name f1fe ;�. �b17 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission} from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS ZF t-) cry NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. A III, IN F-11 V re 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 2014 Page 3 of 7 Ellen L. Cannon ecannonll@msn.com 320 E. Washington Street - Apt. E Iowa City, IA 52240 Cellular: (319) 594 - 8312 Profile • Extensive experience in personnel management, supervision, recruitment, records and data management, daily operations and overall client services • Strong proven record in implementing policies and procedures - • Edncal, dedicated, persuasive and personable style with ability to motiv a amg -"n • Outstanding interpersonal, assessment, referral, presentation, teaching antrftAw skills.— to Professional Experience <r- _0 M -x- a 2008 - Current — Retired, Iowa City, IA c 2006- 2008:Elderly Services/ Bereavement Services Coordinator - OftnurwAlousbWAu thority/ Hospice, Ottumwa, IA Administrated all elderly services for 400+ residents of three separate, high -rise buildings Served as the primary counseling source, at the initial loss of a loved one (400 -600 individuals per year) Provided follow-up calls and visits with families Coordinated family outreach program, utilizing diverse volunteer network Evaluated and referred family members for further grief counseling, if necessary Developed, implemented and facilitated support group programs, bi- annual memorial services 2003- 2006:Staff/ Program Supervisor - SIEDA Substance Abuse Services, Ottumwa, IA Supervised a team of eleven counseling staff members, responsible for providing clinical services to ten south - central Iowa counties Major Duties: Direct supervision of staff; daily operations, program development; QI development -client care and records 2000 -2003: Account Associate - Stewart Communications, Chicaeo,1I. National, state and local experience in promotion and marketing Sole management responsibility for the New Partner section of a national database - Last Acts- National Coalition to Improve Care and Caring for Those Nearing the End of Life, Washington, D.C. 2001: National professional partner contact and pre- broadcast promotion for On Our Own Terms: Moyers on Dying (PBS, 4 -part series on end -of -life issues) Presented series overview and campaign update at AMA Media Briefing, served as adjunct program representative at all Illinois Masonic and Advocate Hospital Coalition meetings, staffed Capitol Hill reception in Washington, DC, provided staff support for broadcast hotline at WTTW. Authored post - broadcast, final evaluation to Moyers parent company. 1997 -2000: Counselor/ Program Developer/ Financial Case Manager - Hazelden Chicago Clinical - Designed and implemented extensive Relapse Prevention programs and provided direct counseling services within Residential, Outpatient and Aftercare programs Financial - Posted to Accounts Receivable, completed pre - certification processes, initiated and completed managed care reviews, made periodic adjustments to accounts, reflecting additional and ancillary services, developed internal financial / billing summary 1993 -1997: Counselor/ Program Developer - ADDS, Burlington, IA / ORHC, Ottumwa, IA Education BACHELOR OF ARTS (Psychology) GPA 3.9 Buena Vista University 1993 - Dean's List- 14 Terms BACHELOR OF ARTS (Human Services) GPA 3.9 Buena Vista University 1993 - Dean's List- 14 Terms 540 Hour Practicum in Chemical Addictions Counseling 1992-1993 IODAPCA / IBSAC Reciprocity -level Certification 1993-2001 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non- member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER 9 Senior Center Member Senior Center Commission Member 0 Non - Resident (Address: ) aOther (Please explain below) February 2014 o n .<r M t7 M c� ru U0 City of Iowa City i 1 Advisory Board /Commission /Committee ' "' ''�' % '"M' =I 'ippl ication Form "I" 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 ATE Hoc SENioR -3 ER0tf -5 Term MY -brc. 90111 NAME WAorui l Noyier HOMEADDRESS 1741 M&KiNhw bR. 5-2x4s- 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? f &4-L- Gender: Male 0 Female© OCCUPATION �e �_ EMPLOYER PHONE NUMBER: HOME-637-q614? BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 64-ptqAl 4eo-v,,� ol,,at P4*4- wueT Ic vni IQ P92PAPNT KNnwi Fnr.i= nF THIS AnviRMY RnARD? M WHAT CONTRIBUTIONS CAN V�r, �F_ 'rT ADVISORY BOARD 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 R No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? RYes FNo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) i Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail i to answer all the questions, Council may not consider your application. General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING CITY OF IOWA CITY Name of City Board /Commission /Committee AP Hoe S,E,VtoR WVICES Date zoi Name NQo*.; 1 40vick Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS oN 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 Address 17-7 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER © Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ) ® Other (Please explain below) February 2014 N C= S� S C-) -- N CA :Crr) -o M „.< W GJ February 2014 City of Iowa City r i Advisory Board /Commission /Committee '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 Senior Service Committee Term 1 NAME Helmut G. Schrott, MD HOME ADDRESS 3117 Alpine Ct, Iowa City, IA 52245 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? 41 years Gender: Male ❑✓ Female OCCUPATION retired physician EMPLOYER formerly UI. PHONE NUMBER: HOME 319 - 351 -5931 BUSINESS n/a EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I have an understanding of epidemiology and demography. I am emeritus professor of the Dept. of Epidemiology, College of Public Health and of the Dept. of Internal Medicine, Carver College of Medicine. I was also Director of the Lipid Research Center and have published more than 100 articles in peer review journals. I believe I can critically evaluate and look at data and issues from both sides and come to a balanced conclusion /opinion which might improve the mission of the currently constituted Senior Center. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? The Ad Hoc Senior Center Service Committee will evaluate the current vision, mission, programs and - complishments of the Senior Center, and evaluate the demographic make -up of the membership, and whether .gments of the senior population are not accessing available services, and whether other services need to be ferred. The committee will make recommendations on how to improve the Senior Center's mission and the Senior enter's functioning and diversity. CAN YOU MAKE TO BOARD (REASON FOR I want the Senior Center to be welcoming, to improve its programming and to improve its diversity. I have extensive experience in recruiting for clinical trials. For example, as part of recruiting for the Coronary Primary Prevention Trial, we screened over 44,000 men (cholesterol, BP, and other health status), ages 35 -59, in over 30 communities. 1 understand the challenges of recruiting minorities and maintaining adherence to study actiies. , LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Confli ' nt t (1) 1 am a member of the Senior Center Program Committee. (2) My wife is a member of the Senior Center Membership Committee. `-ice M. .<r M IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? W✓ Yes NF � DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMIS ON? EYes 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 January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Ad Hoc Senior Service Committee Name Helmut G. Schrott, MD i ,ft `m i �� CITY OF IOWA CITY Date 03/25/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS none a tV NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature WCLIIJ—AL. — Address 3117 Alpine Ct, 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 January 2014 Page 3 of 7 140,Kml- G, Sc-kM&rr ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER V✓ Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ❑ Other (Please explain below) February 2014 ®- ry February 2014 F. James Bradley Byron G. Riley Michael K. Denney Patrick M. Courtney Donald G. Thompson Kelly R. Baler Gregory J. Seyfer Dean A. Spina Joseph E. Schmall Bradley G. Hart William J. Neppl William T. McCartan Maureen G. Kenney Vernon P. Squires Timothy J. Hill Paul D. Burns Janice J. Kerkove March 26, 2014 VIA HAND- DELIVERY Marian Karr Iowa City City Clerk 410 East Washington Street Iowa City, IA 52240 Shannon P. Thompson Kimberly H. Blankenship Joseph W. Younker Jessica A. Doro Natalie K. Ditmars Raymond R. Rinkol, Jr. BRADLEY & RILEY PC s. ATTORNEYS AND COUNSELORS E ADDRESS: CEDAR RAPIDS - IOWA CITY www.bradleyriley.com TOWER PLACE E-MAIL ADDRESS: ONE SOUTH GILBERT STREET jyounker@bradleyriley.com IOWA CITY, IA 52240 -3914 DIRECT DIAL: TELEPHONE: 319- 466.1511 319 -35 8-5569 FAX: 319 - 358 -5560 RE: Iowa City Parks & Recreation Commission Application Dear Ms. Karr: a s. C-)-< Please find enclosed my application for the Iowa City Ad Hoc Senior Services Committee. Please contact me if you have any questions, or if you require any further information. Thank you. Very truly yours, BRADLEY RILEY PC J eph W. ounk JWY /grf Enclosure {01658996.DOCX) City of Iowa City r i Advisory Board /Commission /Committee; ,',N am application Form 4 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 Senior Services Committee Term 5/1/14- 12/1/14 NAME Joe Younker HOME ADDRESS 1011 6th Ave, Iowa City, IA 52240 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? Almost 33 years Gender: Male 0✓ Female OCCUPATION attorney EMPLOYER Bradley & Riley PC PHONE NUMBER: HOME (319) 321 -5587 BUSINESS (319) 358 -5569 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: See Attachment A. VMAR1 10 TVVKMCOC111 r%NUVVLCIJUC Vr 1r11OMUV1QVRT OVARNf F3 .c- See Attachment A.� �► -=f c--> r— _<� M WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLANG)? See Attachment A. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest See Attachment A. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ✓❑ Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? QYes 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 General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Ad Hoc Senior Services Committee Name Joe Younker 1 r i CITY OF IOWA CITY Date 03/20/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS Easo -Et, Inc. 5952 Winthrope Street, Troy Mills, IA 52344 Wife is a shareholder in a family business. 0 4C rn C NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional bus Applicant Signature Address 1011 6th Ave, Iowa 52240 tu 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 2014 Page 3 of 7 Attachment A Experience and /or activities which you feel qualify you for this position: My background as a lawyer will help qualify me for this position. I maintain a general practice including the areas of land use, environmental law, labor and employment, health law, and civil litigation. My practice requires me to engage in creative problem solving, strategic planning, analysis of rules and regulations, and analytical thinking on a daily basis. Through my practice, I am also familiar with assessing financial information and developing budgets. I also have experience serving on other boards and commissions and have engaged in strategic planning for those groups. For instance, I am the President of the Board of Directors of the Iowa City Free Medical Clinic. In the past, I have served as a board member for Corridor Free Wireless, Iowa Volunteer Lawyers for the Arts, and the City High Alumni Association, among others. I am also a graduate of the Iowa City Chamber's Community Leadership Program. I am an honorary native of Iowa City — my family moved here when I was four. I attended Regina, South East, City High, and the University of Iowa. I have worked for many local employers ranging from a hardware store, a factory, and a department store, to a data center and a law firm. I am invested in the community and hope that my experience of growing up in Iowa City will be of benefit to the Committee. Additionally, I serve on the Parks and Recreation Commission, so I am familiar with activities offered through the Parks and Recreation Department. What is your present knowledge of this advisory board? I understand that the Committee will evaluate the current mission, vision, programming, and recent accomplishments of the Senior Center. I understand that the Committee will make a recommendation to the City Council on how resources should be used to meet the needs of Iowa City seniors. I understand that another goal of the Committee is to identify any challenges or obstacles that hinder the City in serving the senior population. What contributions can you make to this advisory board (reason for applying)? Members of our senior community make strong contributions to the City's positive growth. It is important, however, to provide seniors with needed services to ensure that they remain able to enjoy the City and continue to make meaningful contributions. As the senior population increases, it makes sense to evaluate whether or not the City has kept up with the types of programs and services that seniors need. Having been raised in Iowa City, I understand that it is a good place in which to grow up and to grow old. It is in the City's best interest to ensure that young and old alike continue to have opportunities to thrive. The Senior Center has a strong history and I would appreciatethe opportunity to contribute to a strong future for the Center. List potential conflicts of interest: - N) �,.. Although it is unlikely that these relationships would present a conflict of in- t, Imam an attorney with Bradley & Riley PC, my wife is a freelance writer for The ed I serve on the Board of the Iowa City Free Medical Clinic.y -- r.� {01658879.DOC} ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ❑ Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ) ✓❑ Other (Please explain below) Ioowa City resident, non - member of Senior Center. February 2014 c� �Ca 0 r�: -v '7j � i February 2014 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` C fig, �,; d LUG Term NAME L.D L6.5E,,. 1' t%czz1Cj HOMEADDRESS 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? i. y r Jr ` Gender: Male ffl FemaleLO OCCUPATION f FQ _ EMPLOYER :�/`4�c-) Z C` C �� f�j( 0,--7 36 0 >::� '- � ._.. PHONENUMBER: HOMEomga�%'2?d ANMSS r")- ry Z- c­) EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POS91a: -a M o�nnsb�,Co '�skvfe- ��►'9;r'. tyyg - y,o/ � C-,) �' C7 V -5 7 Gvd,7 P DOD FO- E'-.5 U L7-x pa�,61k)C,e it> i , , WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? Tb rn -? YO O rM �l, Li j ca, �' l �S ��✓ ' i�� G ,.S=r ; 4 �/v I Eq� '-oil DP e i 6 WHAT CONTRIBUTIONS CANj YOU MAKE TO THIS ADVISORY BOARD REASONN FOR APPLYING)? J 0 �r0WO �?_ + W lldig. ©'f' 9 � DC✓ %��-- S work, a, 1) rV% w o Ff' i LIST POTENTIAL CONFLICTS OF INTEREST: See Daae 1 for information re_gaMina Conflict of Interest C P 0 1-1 e IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ' Yes R No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR ffOMMISSION? Yes t&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 January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City 1 I A Board /Commission /Committee 5r-! Cfi� -14 G C bw Name LoLt [5a- h CITY OF IOWA CITY Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS N C! d +rte' N NOTE: A new form must be completed if the above information changes or an ownership interest is nnrmired in an addifinnni hiisinPSC- Applicant Signature Address 3.1%0 6 t u)67- % At ow 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 January 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise -available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ❑ Other (Please explain below) February 2014 a m ;< -v -: C'3 rn N) City of Iowa City r` 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 ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Ad Hoc Senior Services Committee Term June -Dec 2014 NAME Jane Dohrmann HOME ADDRESS 337 Ferson Ave, Iowa City, IA Is your home address (listed above) within the corporate limits of Iowa City? F-/]Yes n No How long have you been a resident of Iowa City? 11 years Gender: Male[] Female❑✓ OCCUPATION Social Worker EMPLOYER Iowa City Hospice PHONE NUMBER: HOME 319- 621 -1726 BUSINESS 319 -688 -4214 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I have a Master's degree in Social Work and have worked in the field for over 20 years. I am currently the Director of Honoring Your Wishes and collaborate with with a variety of organizations throughout the community. I have worked with the Senior Center staff in various capacities over the past eleven years. I have experience in program development and evaluation, and working with seniors and diverse populations. Prior to moving to Iowa City, I worked at the Neighborhood Center in St. Paul. This organization provided a variety of services to seniors from diverse populations. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? ° I have spoken with Emily Light, Community Outreach Specialist at the Senior Center and7have rgewe solution 14 -37. C-) As 7 �C ry -o M rn � °- .'- ry WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYING)? I have a commitment to making Iowa City an inclusive and sustainable communitiy. 1 believe that it is imperative to recognize the changing needs of the community and to regularly evaluate how to best meet those needs. I bring experience in working with aging populations, community outreach, program development and evaluation. I believe that I could contribute these skills in assessing the overall needs of seniors in Iowa City. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regardin Conflict of Interest The Senior Center is one of the forty community partners involved with Honoring lour Wishes: A Community -Wide Advance Care Planning Initiative. This initiative is under the leadership of Iowa City Hospice. My spouse's company is an orthopaedic start-up company that is unlikely to ever do business with the city. 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 [,--/]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 January 2014 Page 2 of 7 w lti bra BOARD, COMMISSION AND COMMITTEES `1° , _'- BUSINESS LISTING.._ CITY OF IOWA CITY Name of City Board /Commission/Committee Ad Hoc Senior Services Committee Date 3.26.14 Name Jane Dohrmann Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS I-XHeclux Solutions spouse is majority shareholder) 331 Ferson Ave, Iowa City, ]A 5224UD 0 rQ v� ry NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature �»�-- Address 337 Ferson Ave, Iowa City, IA `Jisrepresentations 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 January 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ❑ Senior Center Member ❑ Senior Center Commission Member ❑ Non - Resident (Address: ) Other (Please explain below) I am a non - member of the Senior Center. N Crs rn -v M mc February 2014 City of Iowa City 1 r 1 — = fir Advisory Board /Commission /Committee Application 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 A A lk� r> �� C-- V-\ ► n r r %j I C- E S Term NAME 'n i- ! rd y e r 'rn alb HOME ADDRESS 3 qq ko-s te r, AL)e- Is your home address (listed above) within the corporate limits of Iowa City? Yes S No How long have you been a resident of Iowa City? g1IAis <3IcE��Gender: Male ❑ FemaleN 1 r OCCUPATION Re -:b rFd EMPLOYER --- PHONE NUMBER: HOMES t q- --� q q `-1 13'? BUSINESS ...w...w.....ww . uwsww w�.w i■.r■ww •u■ uw■. vim■ ■ �1 �■ ■ w ■ ■r% /,/A■ t t—d%r% T" k- AA C- /'1 \I. v■� ■ ■ nv ■ vv■ ■ ■v■.. rE.F r 69 t' � ►0.de. vin tee- c� st,rr�r�� t103ws c&)h, �h WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? J-- At= Q Or t 0::,c,L.vNe_\ 1 ISGto_s -i•a r7 cAtq Q.nyam( 4- WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR RYI ? M 4r,� S�1 a(' Qi'112�►�, t�21�oS� 1. J? r—k Ci �� '� E 1 V nib � �LveW 0.5 ► SS �2Es iz� 5� �d � r�e."s��� � •��m � h � �h �r�'y aen� t � �� a tn I Fa d G Phy et efltJ V1, cno,(! 6 cn'1�►1'ltt� . LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest Q dV)F— IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ZfYes F-] No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes 2No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) to answer Al the questions. Council may not consider vour annlication. General Application January 2014 Page 2 of 7 N _O COMM WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR RYI ? M 4r,� S�1 a(' Qi'112�►�, t�21�oS� 1. J? r—k Ci �� '� E 1 V nib � �LveW 0.5 ► SS �2Es iz� 5� �d � r�e."s��� � •��m � h � �h �r�'y aen� t � �� a tn I Fa d G Phy et efltJ V1, cno,(! 6 cn'1�►1'ltt� . LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest Q dV)F— IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? ZfYes F-] No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? Yes 2No (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) to answer Al the questions. Council may not consider vour annlication. General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Name 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, 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 c O r r i5; Ali 1 43 O� Cal N NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additiop* business. Applicant Signature, Address Le-)O- C S ZZ 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 2014 Page 3 of 7 June Rotman Braverman 349 Koser Ave. o Iowa City, la. 52246 'n 319 - 338 -4139 braveiune @email.com C-) -< Resident Iowa City and University Heights 1951- 2014 M Na EDUCATION Dubuque Senior High School: Diploma University of Iowa: 1951 -1955 BA degree; majors in Speech Pathology & Audiology; Speech & Drama Education. Minor: English Education. Certified K -12 University of Iowa: 1973 MA degree in Communications: Lifetime certification K -12 teacher University of Iowa: 1979 Ph.D. in Education Administration (Primary focus: Education Law) Lifetime certification K -12 teacher, principal, superintendent WORK EXPERIENCE Speech Therapist, Cedar County; Classroom teacher Speech, English, Drama: University High School, Regina High School; Graduate Asst, UI College of Education; Post - doctoral Internship Office of Acting UI President DC Spriestersbach; Director UI Center for Conferences, Institutes and Continuing Education; Associate Director Hancher Auditorium for Grants and Fund Raising; Program Coordinator Iowa City, Johnson County Senior Center; Director, Kirkwood NonCredit Programming for Johnson County. ACTIVITIES Past: Chair Johnson County Democratic Women, Iowa City Community Theatre, Agudas Achim Religious School Committee, Agudas Achim Sisterhood, Precinct Committeewoman. Accompanied various music groups, started and directed a chorus at Oaknoll(1970's), was pianist for silent movies at UI. Created, organized, cast, directed Musical Variety Show fund raisers (1985 -2013) for Iowa City Ronald McDonald House ( two at Hancher with casts of 200 -300); several for Iowa City High School Best Buddies (special needs and general ed students), four for Iowa City Hospice, one for Shelter House, one for Pathways Adult Day Center. Directed shows for Iowa City Community Theatre, the Young Footliters and Regina High School. Founding member of City Circle Acting Co. * N Current volunteer activities - Developed several Chautauqua Summer Events for UHeights with drama, music, activities.Besides fund raising for ICHospice with community shows I started a Hospice chorus which performs sing - alongs at nursing homes monthly, a partnership with ICPublic Library which sends Hospice volunteers to read appropriate books at nursing homes monthly. The library selects and provides the books as part of their outreach program while ICH organizes and sends the volunteers out to read. These programs extend to Williamsburg, Solon, Hills, West Branch facilities. All of t he volunteers in these Hospice programs are senior citizens.Twice a month for some five or six years I have volunteered to do sing - alongs at Pathways Adult Care Center. I have brought the Best Buddies students from City High to sing with this group several times a year as well. Both populations enjoy the interaction. Recently I worked with a group of seniors to bring a documentary on the ripple effects of gun violence on survivors, families and communities to Iowa City in January followed by a panel discussion of gun enthusiasts, the county sheriff, a physician, attorney, a survivor, the director of Mental Health Center and Sen. Bolkum . The work to educate the public, support our mental health institutions and protect our schools is underway with hopefully all concerned at the same table on the same page. I currently have two more fund raisers on the calendar for this summer and a possible third for the fall. All of the show casts are intergenerational with ages ranging from 6 -851 It is apparent that much of my work professionally and as a volunteer has been with or for a senior population. I am not a member of the Senior Center although I was instrumental in making the Senior Center one of the first sites for a New Horizon Band with Steve West of West Music and Myron Welch of UI School of Music while employed at the Center. I did play percussion for some time with the band following my retirement. While at the Senior Center 1 built an extensive catalogue of classes and activities utilizing many of the retired faculty I knew and had worked with at Ul. New programs included the entertainment troupe, Senior Standing Room Only (SSRO) Later I developed a senior market for Kirkwood's non - credit programs in Johnson County. As a retiree 1 have taken some of the UI Senior College classes taught by former colleagues and note that several of their large classes have met at the Senior Center when they lost classroom space on campus because of flooding. o C-J-< -=ice C4 crt cv AWARDS VOLUNTEER SERVICE AWARD :IOWA ADULT DAY SERVICES ASSOCIATION for distinguished service in the cause of the Elderly, 2012 GIRL SCOUT GROWING STRONG AWARD, Mississippi Valley, April 27, 2005 SERVICE TO MANKIND AWARD, Sertoma International Iowa City Chapters, 1986 IOWA CULTURAL CORRIDOR ALLIANCE: 2007 Larry Eckholt Award for Arts, Cultural Advocacy, January 22, 2008 IOWA VOLUNTEER HALL OF FAME LIFETIME ACHIEVEMENT AWARD in recognition of outstanding dedication to volunteer service October 5, 2007 by Gov. Chet Culver CD r C-) co •d.... r en N SELEC&ED PLAQUES RECEIVED ITAG: In appreciation for your support of Iowa's Gifted and Talented Scholars November 2,1987 CHILDREN'S FAMILY LIVING FOUNDATION: For Exceptional Service to the Iowa City Ronald McDonald House Sept.22,1989; October 26,1985; October 17, 1987 Note: a room in the House has been named for my RMH Players who performed for conferences, parties, events for 18 years with all proceeds going to the House. I arranged the programs,music, directed and accompanied the troupe. XIXth AAU /USA JUNIOR OLYMPIC GAMES, IOWA CITY, IOWA, In Appreciation of your contribution to the success... August 5 -11, 1985 (Co- Chair) Senior Center Commission for Outstanding Service To The Senior Center Feb 9, 1995 IOWA CITY /CORALVILLE CONVENTION & VISITORS BUREAU recognition of outstandirrvics President, 1987 -88 July, 1988 NATIONAL UNIVERSITY CONTINUING EDUCATION ASSOCIATION, Conferences & Inst, fet meritorious service as a member of the Executive Committee, April 17, 1988 9 IA. STATE EXTENSION & CONTINUING EDUCATION COUNCIL in recognition of outstanding leadership and service to the State Exten. And Cont. Educ. Council 1982 -1988 Heritage Area Agency Outstanding Initiative in Aging, AARP Chapter 1816 of Johnson County May, 2007 Recognition from the Iowa City Chapter of AARP and the Heritage Agency on Aging for developing and delivering 65 programs in the county celebrating Older American's Month including a Senior Vaudeville Show at the Englert, a USO Show and Dance at the Senior Center with a program on an outdoor stage featuring Congressman Jim Leach and a Presentation of Colors by veterans' groups and ROTC, and a Senior Prom at the IC Children's Museum, a drive for canned good for the Crisis Center, special classes and more! ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER Senior Center Member Senior Center Commission Member © Non - Resident (Address: �; � Kc•) ' r _) Other (Please explain below) February 2014 N C_) t �— M rn ff February 2014 City of Iowa City _ � _ Advisory Board /Com m fission /Com m ittee'`' �kpplication 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 As Hoc Senior Services Committee Term 4 r� NAME Charlotte Walker HOME ADDRESS 1799 5th St, Coralville, IA 52241 Is your home address (listed above) within the corporate limits of Iowa City? 1:1 Yes 0✓ No How Iona have you been a resident of Iowa City? former IA City resident Gender. Male E] FemaleQ OCCUPATION retired EMPLOYER PHONE NUMBER: HOME (319) 354 - -2123 BUSINESS FYaFRIFN(_F ANninR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: can give some economic level balance to the committee. I am very aware of reasons why lower income people stay away from the senior center. I had one year's experience as a member of the Senior Center Commission before moved to Coralville. That experience gave me distressing insights into the management of the facility and about the general negative attitudes towards elders who are very elderly and others who have a low income.ln the past I have worked as a social worker, teacher, activity director in a nursing home, volunteer director in a big hospital, factory worker, sales clerk, telephone operator, waitress, church secretary, and much volunteer activity in poverty groups. )WHAT IS YOUR PRESENT KNOWLEDGE OF THI$"AIMRAY BOARD? I was happy to llearn about this committee and to see that the city council is willing to review the present needs and problems at the Senior Center. It does look like the committee will be made up of mainly upper income people but , hopefullly they will be willing to tolerate opinions and suggestions related to our older lower income people who might like to attend a friendly place to gather for social benefits. I hope the committee will consider discussing a new location for the senior center that has a very close city bus stop, ample free parking, and in a smaller more cheery easy to maintain building. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYING)? do not hesitate to ask question and to question the answers. I have had many years of volunteer experience in forking on low income problems. LIST POTENTIAL CONFLICTS OF INTEREST: See pacLe 1 for information mgarding Con= of Inteest --I =4- C- crl IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? F,(] Yes IOWA CITY BOARD OR.COMMISS E ' s jNo DO YOU CURRENTLY SERVE ON ANOTHER LOW 11 (It has been Council .policy:not to permit an individual to serve on two Boards orcommisS ons at dwsame time.). ... Misrepresentations on this application will constitute just cause for removal'of an appointee. If you fail to answer all th e questions, Council may not consider your application. J. General Application January 2014 Page 2 of 7 WARS, COMNUSSION AND COMWTTEES r BUSINESS LISTING CITY OF I01A :Nam of C4 ;; 4 4h �Aw 1°- a - 1 709 5th 61rWj $2241 Misregwowntakms on Ift appffcafto wit) cortatitute jai for removal ot an appanteo, it ym to an r all stns, +midi t wnsicrn; ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER Senior Center Member Senior Center Commission Member 0✓ Non- Resident (Address: 1799 5th Street, Coralville, IA 52241) Other (Please explain below) i February 2014 Q C, �n r- a "� :=i C., Cn -<r C) City of Iowa City r 1 Advisory Board /Commission /Committee Application Form CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLI 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 Senior Services Committee Term NAME Eve Casserly HOME ADDRESS 1615 Pine Ridge Court - Coralville - 52241 Is your home address (listed above) within the corporate limits of Iowa City? [—] Yes ❑✓ No Female How long have you been a resident of Iowa City? OCCUPATION retired family counselor EMPLOYER PHONE NUMBER: HOME (319) 351 -1135 BUSINESS Gender: Male NA NA 1=xp1=R1FNr_F AND/OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Since I retired, I have participated in various areas of volunteer work regarding older people including: Older Iowans Legislature (served as state vice - chair); Johnson Co. AARP Chapter (served as chair - 4 years); Johnson Co. Task Force on Aging (served as chair for 2 years); Heritage Area Agency on Aging Advisory Counsel (about 8 yrs) and the HAAA Program, Planning & Budget Committee (chair 2 years); Johnson Co Livable Community for Successful Aging Advisory board including serving as chair; Served 1 year on Senior Commission. Wrote newsletters for 3 of shove for a time. Iowa City Hospice volunteer since 1995. Serve on board of my former family services agency. WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? I believe this is a new concept for the City of Iowa City - and thus I know only what description I found on the city web (site. Hopefully the group will seek to address areas of accomplishment, opportunities for inclusion and areas of need for older citizens of both Iowa City and Johnson County (inasmuch as county funding and county older citizen need are factors), will review existing services and will keep an eye to getting as much "bang for the buck" as feasible. WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FQRff PLWNG I've been involved in quite a bit of activity concerning senior citizens and have a hearty i r t in- this araa. .<`-- rn iT? �. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Coa iict of Interest I don't believe that I have any conflicts of interest. I should mention that I currently serve on tw�toralville boards/commissions .... i.e. Civil Service Commission (chair) and Coralville Parks & Rec. Commission (Vice- chair). IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? a Yes U No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? [:] Yes ZNo (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 January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Ad Hoc Senior Services Committee Name Eve Casserly �r #mil moms L CITY OF IOWA CITY Date 03/06/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. P0 1\1.15 BUSINESS NAME BUSINESS ADDRESS None NA w c� s- i �� m q �D NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional Riess. Applicant Signature. Address 1615 Pine Ridge Court - Coralville - 52241 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER Senior Center Member Senior Center Commission Member ® Non - Resident (Address: 1615 Pine Ridge Ct. - Coralville, IA Other (Please explain below) February 2014 C o r- r� � � - Z _-X ry City of Iowa City �- — Boa Advisory Board /Commission /Committee � ��'' A�'�,,. 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 oard /Commission /Committee Name A) HOC Stntor SCrvice.S l.OARifCC Term 'r'//4 ry c NAME 3e4T �e1 �JaGh HOME ADDRESS =LOCUST br., Parl L b�f�i, 5.2317 Is your home address (listed above) within the corporate limits of Iowa City? n Yes N No How long have you been a resident of Iowa City? 1JIA11' 'P&Sft�7�6 ;e+ ee��Gender: Male © FemaleEl OCCUPATION �'t olor Of POot -1uxl j+s 44 bsy l kA EMPl�OYER r►u�� 5-kt- PHONE NUMBER: HOME 31Q -bbl -6695 BUSINESS 31 q- 334 -6165t EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: I,34 years 0FW0rKW.Xfes1ehce cc+ PaAWAYs MOO NY �I:If,G�+�r ih =owia Gi • Li,,Q61e Cow.m�+r+i+ Toli 18W4. C- urr+�,r+ Cku%c� of tt e. �'ol.rson Coup +y °�!' C're s der-r OF +60- Zo wa. A ct o if b ay s ery ices ,Associedi on, WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? — Z hWe r'ta& Ike Je.SC r i0VA arlk SeWe L i+k Dr, "Y" who cxpto►,nek - e - -relotney of` rneeefi � s qy ��oa.1 0 ' -Ae Att HIDC- C,oM AfAAM S -fD YY,vIeuJ GCN I_vi'f" i or' w Vices I h ti L- t oT eed IJ WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FORAPPLYING ? ktve 14not&led, je jrF Many o-F -f1 S¢rito' SexviceS p°vi iA -ToWa. C,;+y ate. Job tson cJw"f Y• LIST POTENTIAL CONFLICTS OF INTEREST: See pape 1 for information renarding Conflict of Interest drop to a- �a-%w,%rs vlf lar hkaM Cw, . (1Zzmiw, fo4ing -grow. Rowe, cay A +d-ko Ag�►a+es tl.�e�l. `�'�� �i8uS1nQ 4ed CoM�w►�-r velopae�f"CorKM�s-sian� IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? nYes U No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? a es ENO (It has been Council policy not to permit an individual to serve on two Boards or Commissions -the sage time.) Misrepresentations on this application will constitute just cause for removal of an a64te�If yowl to answer all the questions, Council may not consider your application. `? `< o r" veneral Application Zz January 2014 Page 2 of 7= rQ BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING 1 � ....rte .�• MUM CITY OF IOWA CITY Name of City Board /Commission /Committee -AJ Hoc �nor � Crylc 5 6mitDate 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, 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 Monet N a C-) "� N -<r- rim NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business, Applicant Signatui Address 380 L br. , N vr-h�UW�, -MA 5x317 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ElSenior Center Member Senior Center Commission Member VN Non- Resident (Address: 380 Zocu f )f.j P)A L,Lx" 50317 F] Other (Please explain below) February 2014 a ca X_ ra a ISO i" �ti rV O City of Iowa City I, r i 011 X Advisory Board /Commission /Committee ` --"'+ v 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 Senior Services Committee Term , May-Dec. '14 NAME Erin Linn Robinson HOME ADDRESS 809 20th Ave, Coralville, IA 52241 Is your home address (listed above) within the corporate limits of Iowa City? [:] Yes 0✓ No How long have you been a resident of Iowa City? N/A Gender: Male F� Femalez OCCUPATION PhD Student in Social Work / MPH Student EMPLOYER University of Iowa PHONE NUMBER: HOME (314) 809 -0063 BUSINESS N/A EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: have a Master's of Social Work degree and am currently pursuing my PhD in Social Work and Master's of Public lealth degree at the University of Iowa. I specialize in gerontology, particularly HIV and aging. In the past, I have erved as an associate director for a non - profit organization in St. Louis, MO that provided case management and ;ferral services to low- income older adults. I have experience working collaboratively on interdisciplinary teams, as fell as program /project evaluation experience. •w w� nwwwv w� � www VVnr%l 10 i VYR rRG%-7G1Y 1 F%IrV VV %'a /1V V IVVRI wAnv r t- I am currently completing an internship for my MPH program with the Senior Center and Am tfoved ab U t this committee through Senior Center staff. c-)-.< N -=� c-) a� �- M .<r � YOU MAKE TO THIS With my background and specialized interest in aging, I can contribute my knowledge of healthy aging throughout the lifespan. This includes knowledge gained through my education and as well as a social service provider. In addition, have experience conducting program evaluations, which will prove beneficial as the committee undertakes this evaluation of services available to seniors in Iowa City. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest As stated, I am currently completing an internship with the Senior Center. I expect to be finished with my hours for this internship by the time this ad hoc committee is formed. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? F✓ Yes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes 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. General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Ad Hoc Senior Services Committee Name Erin Linn Robinson CITY OF IOWA CITY Date 03/26/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS NONE 0 C) �� .. CA NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signature. Address 809 20th Ave, Coralville, IA 52241 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ❑ Senior Center Member Senior Center Commission Member 9 Non - Resident (Address: 809 20th Ave, Coralville, IA 52241 ) ❑ Other (Please explain below) February 2014 N O � r -< c-n 11-0 February 2014 y CITY OF IOWA CITY MEMORANDUM Date: March 26, 2014 To: Mayor and City Council From: Marian K. Karr, City Clerk Re: Ad Hoc Senior Services Committee — Council Member Appointment On April 1 you will be making appointments to the Ad Hoc Senior Services Committee. RES. 14 -37 establishing the Committee requires at least one member of the Committee to be a City Council Member. Although not required, Council Member Dobyns has submitted an application reconfirming his interest in being the City Council appointee. City of Iowa City ( i Advisory Board /Commission /Committee., , Application Form CITY OF IOWA CITY THIS APPLICATION IS A PUBLIC DOCUMENT AND AS SUCH CAN BE REPRODUCED AND DISTRIBUTED FOR THE PUBLI� WITH THE EXCEPTION OF THE LAST PAGE MARKED "CONFIDENTIAL." THIS APPLICATION WILL BE CONSIDERED FOR THREE MOMMiS ONLY AND AUTOMATICALLY CONSIDERED FOR ANY VACANCY DURING THAT TIME. Advisory Board/Commission/Committee Name Senior Service Committee Term N/A NAME Rick Dobyns HOME ADDRESS 1950 Calvin Ave, Iowa City Is your home address (listed above) within the corporate limits of Iowa City? o Yes No How long have you been a resident of Iowa City? 26 years Gender: Male ✓] Femalen OCCUPATION Physician /UI Faculty EMPLOYER University of Iowa PHONE NUMBER: HOME 354 -3220 BUSINESS 530 -3881 EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: Geriatric medical specialist and medical consultant in active practice and teaching Public Health Master's Degree Past member of: Johnson County Board of Health, Visiting Nurses Association Board, Iowa City Hospice medical director and board member, Elder Service Inc. board. Johnson County Liveable Community task force Member: Iowa City Council W. _. T IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? This committee ll evaluate current services for older members of the Iowa City community., , dete wi rmineny changes or enhancements that should be recommended to the Oity Council. -ar tai �M WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYING)? My professional background and most of my voluntary efforts have been devoted to holistic care of the older citizen. My role as a city council member will assist the committee in preparting the recommendations that will ultimately come to the council. LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest I have no financial potential conflict of interest in any community entity. A very small part of my salary at the University is based on the productivity of my medical care of the elderly. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? FVJ Yes [:] No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes [t-/�No (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. General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Senior Service Committee Name Rick Dobyns - CITY OF IOWA CITY Date 3/1/14 Section 362.5 of the Code or Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouseldomestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS n Q C> r .F" rat C=' z �- ra NOTE: A new form must be acquired in an additional Applicant Address 1950 Calvin Ave, Iowa City if the above information changes or an ownership interest is 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 2014 Page 3 of 7 ATTACHMENT TO APPLICATION FOR THE AD HOC SENIOR SERVICES COMMITTEE The Senior Service Committee shall consist of seven (7) members to be appointed by the City Council. Members of other City boards and commissions may serve on the Senior Services Committee. Membership shall include at least one member of the City Council, Senior Center Commission and a non - member of the Senior Center. Up to two non - residents of the City of Iowa City shall be eligible to serve on the committee if they are residents of Johnson County and offer desirable expertise available from applicants who reside in Iowa City. CHECK ALL THAT APPLY FOR COUNCIL TO CONSIDER WHEN CHOOSING A MEMBER ✓0 February 2014 Senior Center Member Senior Center Commission Member Non - Resident (Address: ) Other (Please explain below) N E5 m Oil Cn :ern -v � r 04-01-14 11b NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: AIRPORT COMMISSION One Vacancy — Four Year Term March 1, 2014 - March 1, 2018 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, March 26, 2014. 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. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step - mother, step- child, aunt, or uncle. (Resolution 85 -354) Males: 2 Females: 2 Council Announcement Date: November 12, 2013, January 7, 2014, February 18, 2014 Application Deadline: Wednesday, 5:00 p.m., March 26, 2014 Council Appointment Date: April 1, 2014 After 02/10/2014 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. AIRPORT COMMISSION One Vacancy - Four Year Term March 1, 2014 - March 1, 2018 Term expires for Howard Horan Gender Balance Requirement: 1 None No Applications as of Wednesday, 5:OOp.m., March 26, 2014 ElDenotes applicant completed the Confidential page of the application. 04-01-14 11C 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, 2014 - December 31, 2018 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, March 26, 2014. 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: August 20, 2013; September 17, 2013, November 12, 2013, December 17, 2013, February 18, 2014 Application Deadline: Wednesday, 5:OOp.m., March 26, 2014 Council Appointment Date: April 1, 2014 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 Previously advertised; term expired for Dennis Keitel January 1, 2014 — December 31, 2018 Gender Balance Requirement: None No Applications as of Wednesday, 5:OOp.m., March 26, 2014 ❑x Denotes applicant completed the Confidential page of the application. Ila 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, March 26, 2014. 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; July 31, 2012; September 4, 2012; October 23, 2012; December 4, 2012; January 8, 2013; February 19, 2013; March 19, 2013; April 23, 2013; June 4, 2013; July 23, 2013; August 20, 2013; September 17, 2013, November 12, 2013, December 17, 2013, February 18, 2014 Application Deadline: Wednesday, 5:OOp.m., March 26, 2014 Council Appointment Date: April 1, 2014 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., March 26, 2014 El Denotes applicant completed the Confidential page of the application. 11e ,rest[ $I � THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: BOARD OF APPEALS One Vacancy — Five -Year Term January 1, 2014 - December 31, 2018 It is the duty of members of the Board of Appeals to hold appeal hearings on matters concerning the International Building Code, International Residential Code, Uniform Plumbing Code, National Electric Code, International Mechanical Code, International Fire Code, and the Iowa City Housing Code. Members must be qualified by experience and training to pass upon matters pertaining to building construction. Iowa City appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Board meets the first Monday of each month at 4:00 p.m. or at the call of the Building Official. Applications must be received by 5:00 p.m., Wednesday, March 26, 2014. The City of Iowa City encourages diversity in the appointment of citizens to boards and commissions. Persons interested in being considered should contact the City Clerk at City Hall, 410 E. Washington Street. Application forms are available from the Clerk's office upon request or on the City website at www.icgov.org. Questions regarding the Board of Appeals should be directed to Tim Hennes, Sr Building Inspector at 356 -5122. Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 3 Females: 1 Council Announcement Date: 1- October -2013, November 12, 2013, December 17, 2013, February 18, 2014 Application Deadline: Wednesday, 5:00 p.m., March 26, 2014 Council Appointment Date: April 1, 2014 After 01/27/2014 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. BOARD OF APPEALS Gender Balance Requirement: 1 Female One Vacancy — to fill a five year term January 1, 2014 - December 31, 2018 Term expires for Chad Campion No Applications as of Wednesday, 5:OOp.m., March 26, 2014 El Denotes applicant completed the Confidential page of the application. L4-01 -14 11f NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: HISTORIC PRESERVATION COMMISSION One Vacancy — Three Year Term March 29, 2013 - March 29, 2016 (1) Jefferson St Representative Duties of the Historic Preservation Commission include: conducting studies for the identification and designation of Historic Districts; reviewing and acting upon all applications for Certificate of Appropriateness; cooperating with property owners and city agencies regarding remedy of dangerous conditions; furthering the efforts of historic preservation in the City by making recommendations on preservation issues, when appropriate, by encouraging the historical, architectural or cultural value, and by encouraging persons and organizations to become involved in preservation activities. This Commission meets the second Thursday of each month at 5:30 p.m and, if necessary, the fourth Thursday of each month at 5:30 p.m. Iowa City appointed members of the boards and commissions must be eligible electors of the City of Iowa City. Applications must be received by 5:00 p.m., Wednesday, March 26, 2014. 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 Historic Preservation Commission should be directed to Bob Miklo, Sr Planner at 356 -5240. 2/19/2014 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: 5 Females: 5 Council Announcement Date: February 5, 2013; March 19, 2013; April 23, 2013; June 4, 2013; July 23, 2013; August 20, 2013, September 17, 2013, November 12, 2013, December 17, 2013, February 18, 2014 Application Deadline: Wednesday, 5:00 p.m.; March 26, 2014 Council Appointment Date: April 1, 2014 After 05/06/2013 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. HISTORIC PRESERVATION COMMISSION One Vacancy - Three Year Term March 29, 2013 — March 29, 2016 Gender Balance Requirement: 1 None Jefferson St District Representative (New District) No Applications as of Wednesday, 5:OOp.m., March 26, 2014 El Denotes applicant completed the Confidential page of the application. NOTICE 11g THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING BOARD: BOARD OF LIBRARY TRUSTEES One Vacancy - Unexpired Term Effective Upon Appointment - June 30, 2015 The Board of Library Trustees is a semi - autonomous body of nine persons empowered by State Law to plan, direct, and control all affairs of the Public Library. This includes determining long -range goals of Library service, adopting written policies to govern operation of the Library, and employing a competent staff to help plan and implement the Board's service goals. Iowa City appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Library Board meets the fourth Thursday of each month at 5:00 p.m. Applications must be received by 5:00 p.m., Wednesday, March 26, 2014. 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 Board of Library Trustees should be directed to Susan Craig, Library Director at 356 -5200. 2/7/2014 z0Ox�c m II II u u > Z > 6 N Q L fD CD 3 (D m x O n C (DD 0- XI X I X I X I Q �l< Ixlxlx x x x X X x Q x x 3 n n N I �D X X X 3 X p C s(D x nm �. V Q, fD m m a N W X X X I X X x X x v m 1 fD — 0 Q a oll rn rn rn rn rn rn rn rn rn rn Y y \ \ \ \ \ \ \ \ \ \ \ IP w W W W W w w W W W w O O O O O O O O O O O 1--A N N F- f: O v v W cn v Uo vi w w tD W x p x p x x z x x x Z m m 0 0 7 7 _ 0 Q 0 x x x x x x N x x O n m XI X I X I X I Q �l< Ixlxlx x x x X X x Q x x I m I X X X X X p X X x m m X X X X I X X x X x X X X Q X X Q X x Q X m M 0 0 sv d Q Q X I X X x X X Q X X I X I X I X I o I X I X 1 0 1 X I IX I X I X I X I o I X I X 1 0 1 1X �XI X I X I X IXIoIp1XI IX n >w z o X z 0 > o3 NnN W X 2 n V 00 0 d a 0 2 N 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: 5 Council Announcement Date: February 18, 2014 Application Deadline: Wednesday, 5:00 p.m., March 26, 2014 Council Appointment Date: April 1, 2014 After 05/19/14 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. LIBRARY, BRD OF TRUSTEES One Vacancy - Unexpired Term Effective Upon Appointment - June 30, 2015 (Mark Edwards resigned) Gender Balance Requirement: 1 Male (M) David Hamilton El 814 N. Linn (M) Dale Kraus 0 4222 Cumberland Ln El Denotes applicant completed the Confidential page of the application. City of Iowa City I P �A _ _ Advisory Board /Commission /Committee l'��'''� %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 Named `' L'� r'�- °�2G�f Term c NAME Vr 41n, HOME ADDRESS 7-1 if • L- h v, Is your home address (listed above) within the corporate limits of Iowa City? ZYes F1 No How long have you been a resident of Iowa City? 3 ti e-AA -A Gender: Male VFema[eE] OCCUPATION V-e-g cj EMPLOYER i,L vL S PHONE NUMBER: HOME 5f 3�1- -- 3s--� (� BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: i<L 0— k;,_4 4� , N a WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? _? c-� ry :qn CA 4 1 WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FOR APPLYING)? LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest dt)-A-)-_ IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? [OYes ❑ No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes 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. I General Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING I r � ;1�`'.Nx - i **%JM6- CITY OF IOWA CITY Name of City I Board /Commission /Committee rk-t Date 312-4-11 4� 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, 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. USINESS NAME BUSINESS ADDRESS a =- c-) U, FMM -=r NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional business. Applicant Signatu Address :�l q 9 , L-- ► VX V\ 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 2014 Page 3 of 7 City of Iowa City i r Advisory Board /Commission /Committee' - "'+�1''�� wr ®I 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 Library Trustee Term unexpired NAME Dale D. Kraus HOME ADDRESS 4222 Cumberland Ln, Iowa City, IA 52245 Is your home address (listed above) within the corporate limits of Iowa City? R Yes F-J No How long have you been a resident of Iowa City? - 2 years Gender: Male ✓0 Female OCCUPATION Retired PHONE NUMBER: HOME 319- 930 -8907 EMPLOYER previous - USDA BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: have served as a board member and executive director to various local and regional organizations in other nations, both in a volunteer and in a professional capacity. These have included a multi- county nonprofit rural evelopment corporation, an area economic development corporation, a county foundation and church board of c-- .C- YYnAI io T VUR rmcac 1 1%NVVVLCIJbC Vr I nia AUviaum 6VARU r n =il I currently have only a limited general knowledge of the Board of Library Trustees. I am a Obtfon O-Rhe IOW&City Public Library and the libraries in other communities where I have lived. 0, .<r- �. Iii M .. ,x ,- WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD (REASON FORAPPLYING)? eing retired and a relatively new resident of Iowa City, I have the desire to become active in the local cummunity in volunteer capacity. I am experienced in identifing resources, needs and opportunities. I have coordinated the ormation of community development groups, served as a grant writer and prepared financial packages, prepared nd reviewed business plans, assisted in setting priorities and implementing established goals. 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? n Yes n No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? n Yes FNo fIt 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 Annlication BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board /Commission /Committee Library Trustee Name Dale D. Kraus � r 4m iiii CITY OF IOWA CITY Date 03/26/2014 Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME BUSINESS ADDRESS C) � rn .. NOTE: A new form r acquired in an additi Applicant Signature, completed if tl6 above information changes or an ownership interest is Address 4222 CumberlarYd Ln, 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 Aonlication 04 -01 -14 11h NOTICE THE CITY COUNCIL OF IOWA CITY IS CONSIDERING APPOINTMENT TO THE FOLLOWING COMMISSION: TELECOMMUNICATIONS COMMISSION Two Vacancies — Three -Year Term March 13, 2014 - March 13, 2017 The duties of the Telecommunications Commission include serving as a review board to resolve disputes between any subscriber or potential subscriber and the cablevision company; reviewing and auditing reports by the cablevision company to the City as required by the Cable Television Ordinance; working with the public, the media, the City, and the cablevision company for the purpose of making recommendations on various issues; engaging in other activities pursuant to the effective monitoring and evaluation of the CATV system in the City. Iowa City- appointed members of boards and commissions must be eligible electors of the City of Iowa City. The Telecommunications Commission meets the fourth Monday of each month at 5:30 p.m. Applications must be received by 5:00 p.m., Wednesday, March 26, 2014. 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 Telecommunications Commission should be directed to Bob Hardy, Cable Television Administrator at 356 -5047. 2/19/2014 TELECOMMUNICATIONS COMMISSION 12 MONTH ATTENDANCE RECORD (X) = Present (0) = Absent (O /C) = Absent/Called (Excused) Hoemchelman Be us Homewood 5/28/11 X X X X x 6/27/11 x o/c x x X 8/27/11 x x x o/c X 9/24/11 X X X X X 10/24/11 X X X X X 11/26/11 X X vacant X X Kilburg 2/25/12 X X x x X Butler 3/26/12 o/c x o x X 4/23/12 X X X X X 5/21/12 X X X X X 6/25/12 X X X X X 7/23/12 x X X X X 8/27/12 x x x x X 9/24/12 X X X X X 10/22/12 X X X X X 11/26/12 X X X X X 12/17/12 X X X X X 1/28/13 X o/c X X X 2/25/13 X X X X X Elias 3/25/13 o/c x o/c x X 4/22/13 x x x x 0 6/3/13 X X X X X 6/24/13 x o/c z o/c X 7/22/13 o/c x x x X 9/23/13 x X X X o/c 10/28/13 X X X X X 12/30/13 O/C X O/C X X 1/27/14 X X X X X 2/24/14 X X X 0 0 (X) = Present (0) = Absent (O /C) = Absent/Called (Excused) Spouses and relatives of City Council Members and members of comparable County Boards and Commissions are not eligible for appointment to City Boards and Commissions. This includes: spouse, child, mother, father, mother- in- law, father- in- law, brother, sister, brother- in- law, sister- in- law, step- father, step- mother, step - child, aunt, or uncle. (Resolution 85 -354) Males: 2 Females: 1 Council Announcement Date: November 12, 2013, January 7, 2014, February 18, 2014 Application Deadline: Wednesday, 5:00 p.m., March 26, 2014 Council Appointment Date: April 1, 2014 After 02/10/2014 (3 mo from the announcement date) Council may appoint any qualified applicant without regard to gender. TELECOMMUNICATIONS COMMISSION Two Vacancies - Three -year Term March 13, 2014 — March 13, 2017 Term expires for Nicholas Kilburg and Alexa Homewood Gender Balance Requirement: 1 Female, 1 None (F) Alexa Homewood 0 (Currently serving first three year term) 1229 Arthur St. (M) Nicholas J. Kilburg 0 (Currently serving unexpired term) 1918 Meadow Ridge Lane 0 Denotes applicant completed the Confidential page of the application. City of Iowa City i r Advisory Board/Commission/Committee ,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 Term L _ NAME �>���i(' HOME ADDRESS Is your home address (listed above) within the corpor-a�tte limits of Iowa City? 12 Yes F1 No How long have you been a resident of Iowa City? ,�� Gender: Male ❑ Female OCCUPATION ..�f�5�/l'Q1 a AWM- EMPLOYER gT66(r PHONE NUMBER: HOME 31 �q BUSINESS EXPERIENCE AND /OR ACTIVITIES WHICH YOU FEEL QUALIFY YOU FOR THIS POSITION: 1 haGt� 5e�( d CAS C�i�lm ss o �� 4Lt -16 -� 7 S} - �i9J r Sh CG1?'�fr/l G 5 G11�i •l �� rc���r�llii�i�� !V = own WHAT IS YOUR PRESENT KNOWLEDGE OF THIS ADVISORY BOARD? wE �nw &C-w h)crk /)-7 DA cob cx � %crn oe G/W%2<f QC05 S '�I;PSJ �m t'� 9 CA) WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? we u l d 14e, 4e) C �` % i'� Lam' 1 ii G�1'� '941 ✓s% Svi ' LIST POTENTIAL CONFLICTS OF INTEREST:tgee page 1 for information regarding Conflict of Interest .v M IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? M Yes n No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? nYes ,E]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 January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES �• �' r� "ti BUSINESS LISTING_ CITY OF IOWA CITY Name of City ILTC Board /Commission /Committee Date Ja Z&121 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, 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 a C) r- _<r— rn i' NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional busirips. I Applicant Signature/ 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 2014 Page 3 of 7 City of Iowa City Advisory Board /Commission /Committee A MN 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 Iowa City Telecommunications Commission Tenn 2014 NAME Nicholas J. Kilburg HOME ADDRESS 1918 Meadow Ridge Lane Is your home address (listed above) within the corporate limits of Iowa City? R✓ Yes [] No How long have you been a resident of Iowa City? 6.5 years Gender: Male ❑✓ Female[] OCCUPATION Attomey EMPLOYER Elderkin & Pimie, PLC PHONE NUMBER: HOME (Cell) 319.899.3421 BUSINESS w union w 0+1rnnrice wulf"u WWI I S:FFI nI IAI_IFY YOU FOR THIS POSITION: GArGtI�G {wG I1�wivf� w ......L.V ... uv.. • -- -- - - - - - - - - Previous service on board; experience as an attorney in working with contracts 0 ww t www �` �.i 5C7 HAI 15 YVUK Mr-=IV i n11uvYLcuVc ur I nio nuviown r ovr+RV r Tently serving as a member "fr ^' 1 ;<m M Z WHAT CONTRIBUTIONS CAN YOU MAKE TO THIS ADVISORY BOARD REASON FOR APPLYING)? Continuing service to the Commission; ongoing- accumulation of experience in the field to be applied in service of the Commission LIST POTENTIAL CONFLICTS OF INTEREST: See page 1 for information regarding Conflict of Interest One of the partners in my fine is currently involved in a suit against the City; I am not involved in this case in any way and will not be. IF YOU ARE NOT SELECTED, DO YOU WANT TO BE NOTIFIED? 0 Yes F-1 No DO YOU CURRENTLY SERVE ON ANOTHER IOWA CITY BOARD OR COMMISSION? n Yes QNo (It has been Council policy not to permit an individual to serve on two Boards or Commissions at the same time.) Etoarnswer presentations on this application will constitute just cause for removal of an appointee. If you fail all the questions, Council may not consider your application. ,. veneral Application January 2014 Page 2 of 7 BOARD, COMMISSION AND COMMITTEES BUSINESS LISTING Name of City Board/Commission/Committee Iowa City Telecommunications Commission r �� CITY OF IOWA CITY Date 03/10/2014 Name Nicholas J. Kilbur Section 362.5 of the Code of Iowa generally prohibits, with certain important exceptions, a member of a city Board or Commission from having an interest in a city contract. A copy of Section 362.5 is attached (see page 7). List all businesses in which you, or your spouse /domestic partner, have an ownership interest (for example, sole proprietor, partner, 5% or more of corporation's stockholdings). Please indicate if there are none. BUSINESS NAME N/A BUSINESS ADDRESS N O C) `C ••� 0 Ci NOTE: A new form must be completed if the above information changes or an ownership interest is acquired in an additional ,pplicant Signature, l address 1918 Meadow Ridge Lane V �---� Misrepresentations on this application will constitute just cause for removal of an appointee. If you fail enswer all the questions, Council may not consider your application. leneral Application anuary 2014 Page 3 of 7