Created Aug-2020
Application for Appointment to
Police Station Feasibility Ad-hoc Committee
PLEASE PRINT
Applicant Name:
Home Address:
City, Zip:
Home Phone:
Cell Phone:
Email:
Mailing Address:
City, Zip:
Do you live within the city limits of St. Helens? Yes No If yes, how long? Years Months
Civic Activities (offices held, honors, etc.):
List names, email addresses, and phone numbers of three references not related to you:
Briefly summarize educational background:
Present Employer Name: Phone:
Present Employer Address:
Title of Position Held:
Additional information you wish to include:
I hereby certify that the information provided above is true and accurate to the best of my knowledge. If appointed, I
agree to not participate in any proceeding or action in which there may be a direct or substantial financial interest to myself,
my relatives or a business I or my relatives are associated with, including any business with which I am serving on their
board or have served in the previous two years; or any business with which I am negotiating for or have an arrangement
or understanding concerning prospective partnership or employment. I agree to disclose any actual or potential conflict of
interest at the meeting where the action is being taken.
Signature: Date:
Please return to: Kathy Payne, City Recorder Questions? Please call: (503) 366-8217
St. Helens City Hall
265 Strand Street
St. Helens, OR 97051
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