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305 N. Mt. Shasta Blvd. Mt. Shasta, CA (City of Mt Shasta)

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U.S.A. forms for City of Mt Shasta

BROWSE CITY OF MT SHASTA (CA) FORMS

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305 N. Mt. Shasta Blvd.
Mt. Shasta, CA 96067
To Applicants for Brown Act Commissions/Committees:
Thank you for your interest in volunteering to serve on a City Commission/Committee. Please be
advised that members of a Brown Act Commission/Committee are subject to the Political Reform Act
which requires that public officials should not participate in decisions that are economically
advantageous to them. Therefore the City’s Resolution No. CCR-11-51 requires the filing of a 700 Form
with the City Clerk by Commission/Committee Members within 30 days of appointment or prior to their
participation in the meetings of the Commission/Committee to which they have been appointed.
The purpose of the Form 700 is to provide, for disclosure purposes, the personal assets and income of
public officials, salaried or unsalaried, who possess decision making authority, affecting public
investments through their decisions or who provide recommendations that are regularly approved by
another public official or governmental agency.
Although, at first glance, the 700 Form may appear to be a daunting document, the reality is that most
filers are only required to complete the cover page and one or two of the schedules, as most of the other
schedules are not applicable.
All Members of Commissions/Committees must complete applicable pages of the 700 Form as follows:
Cover Page: All filers must complete.
Schedule A-1: Use this schedule to report stocks, bonds, and other investments in entities located in,
doing business in, or plan to do business in the City of Mt. Shasta.
Schedule A-2: Use this schedule to report any businesses that you, your spouse or registered domestic
partner have a greater than 10% interest in or that provides you with revenues over $2,000 that is located
in, doing business in, or plans to do business in the City of Mt. Shasta.
Schedule B: Use this schedule to report any interest you or your spouse might have in real properties
located in the City of Mt. Shasta, other than your principal residence.
Schedule C: Use this schedule to report other sources of income, such as income from a loan you may
have made or spousal or registered domestic partner income. Again only report those income sources
from business that are located or are doing business in the City of Mt. Shasta.
Schedule D: Probably NOT APPLICABLE. This is a reporting of a gift or combination of gifts or
income donated to you by another party whose value or combined value is $50 or more. It is the
acceptance of the gift not ultimate use of the item that is reportable.
Schedules E & F: NOT APPLICABLE. This is a reporting of any travel advances or reimbursements.
None of the City’s Brown Act Committee Members seldom do any traveling on behalf of the City that
qualifies for reimbursement by the City and you are not required to report payments received for which
you provided services equal or greater in value than the payments received.
Again, thank you for your willingness to give of your time and efforts on a volunteer basis. Should you
have any questions or require any further information, please feel free to contact me.
Sincerely,
Kathryn Wilson
Deputy City Clerk
APPLICATION FOR APPOINTMENT
TO BOARDS/COMMISSIONS/COMMITTEES
_______________________________________________________________________
(Please specify which Board/Commission/Committee for which you are applying)
The Mt. Shasta City Council is seeking area residents who wish to serve on a Board, Commission or Committee which
has been established to assist and advise the City Council on specific matters. Please complete this application in full
(attach a resume or other information which may assist the City Council in making its selection) and file the completed
document with the Mt. Shasta City Clerk.
NAME:_________________________________________HOME TELEPHONE:______________________
CELL TELEPHONE:______________________ EMAIL ADDRESS:_______________________________
HOME ADDRESS:____________________________________CITY:___________________ZIP:_______
BUSINESS NAME:___________________________________WORK TELEPHONE:_________________
Resident of Mt. Shasta area for ____ years. Do you live inside or outside the city limits?
Are you a registered voter? Yes No
How did you become aware of the vacancy?
Please state briefly your reasons for applying and why you feel you are qualified for appointment to this body (Use
additional paper, if necessary):_______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Educational Background/Degrees:____________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Presently Employed By:_______________________________Current Position:_________________________
Planning Commission Applicant Provided With Planning Commissioner Candidate Questions □
Page 2 of 3
Are you currently serving on any other City Council appointed Board, Commission or Committee?
No Yes; If yes, list here: ______________________________________________________________
________________________________________________________________________________________________
Have you previously served on any other City Council appointed Board, Commission or Committee?
No Yes; If yes, list here: ______________________________________________________________
________________________________________________________________________________________________
Please describe your past and present community involvement including voluntary, social, city, church, school,
business, and/or professional associations you have been involved in and are applicable to this application (Include
dates of involvement): _____________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
List any State, County or Municipal Boards or Commissions you are presently or have previously served on:
________________________________________________________________________________________________
________________________________________________________________________________________________
A short summary of your vision for the Commission or Committee’s contributions to the future of Mt Shasta:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Are you available to attend daytime meetings? YES NO
Are you available to attend evening meetings? YES NO
Page 3of 3
Local References:
NAME
AFFILIATION
FIRM
ADDRESS
TELEPHONE
John Doe Example
Former
Supervisor
Personnel
Preference
825 John Doe Avenue
Mt. Shasta
(530) 926-9999
I HEREBY CERTIFY THAT THE FACTS, STATEMENTS, AND INFORMATION PRESENTED WITHIN THIS APPLICATION ARE TRUE
AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY OR ALL INFORMATION ON THIS
FORM MAY BE VERIFIED. I UNDERSTAND THAT ANY MISREPRESENTATION OR OMISSIONS OF ANY INFORMATION REQUIRED
IN THIS APPLICATION MAY RESULT IN MY APPLICATION BEING DENIED BY THE CITY OF MT. SHASTA. I UNDERSTAND AND
AGREE THAT THIS DOCUMENT IS A PUBLIC RECORD SUBJECT TO DISCLOSURE UNDER THE PUBLIC RECORDS ACT.
Dated: _________________________ Signature: ______________________________________
The City of Mt. Shasta advises the public, employees, and job applicants that it does not discriminate on the
basis of race, color, religion, national origin, sex, sexual orientation, age, or handicap status in providing its
services, programs, benefits and employment.
RETURN THIS FORM TO:
ATTN: DEPUTY CITY CLERK, CITY OF MT. SHASTA, 305 N. MT. SHASTA BLVD., MT.
SHASTA, CA 96067
For
information call (530) 926-7510
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305 N. Mt. Shasta Blvd. Mt. Shasta, CA (City of Mt Shasta)

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Completed 14 July 2020

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