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2. Date
   Date
4. First Name*
5. Middle Name
6. Last Name*
8. Phone*
10. Address1*
12. Address2
14. City*
15. State*
16. Zip*
18. Occupation*
19. Employer*
21. Work Address1
23. Work Address2
25. City
26. State
27. Zip
29. Work Phone
30. Fax
32. Email*
34. I am interested in serving on the Parking Study Stakeholder Advisory Group as a:*

    Please check one

    1. Downtown Business Owner
    2. Downtown Employee
    3. Ferry Commuter

    1. PSNS Employee
    2. Olympic College Student
    3. Other
36. If other, please explain
38. Why are you applying for this appointment?
40. Which of your personal and / or professional interests prompted you to apply for this appointment?
42. Please list your qualifications for this appointment (include skills, activities, training, education):
44. We welcome your willingness to serve Bremerton. For more information please contact the City Clerk's Office by phone at 360-473-5323 or via email.
    
    Pursuant to the Washington Public Disclosure Act, (RCW 42.56), this form constitutes a public record and is subject to public release upon request. Prior to release, the following information may be redacted pursuant to RCW 42.56.250(3): Residential addresses, residential telephone numbers, personal wireless telephone numbers, personal electronic mail addresses, social security numbers, driver’s license numbers, identicard numbers, and emergency contact information of employees or volunteers of a public agency, and the names, dates of birth, residential addresses, residential telephone numbers, personal wireless telephone numbers, personal electronic mail addresses, social security numbers, and emergency contact information of dependents of employees or volunteers of a public agency.
    
    Applicants are considered for appointment without regard to race, color, religion, gender, national origin, sexual orientation, age, genetic information, marital or veteran status, or the presence of any disability.
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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

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