City Forms - LA County West Vector Control District Application

Member must be a registered voter in Santa Monica.

* indicates required information

INFORMATION TO BE DISPLAYED ON INTERNET:

Prefix*:
First Name*: Middle Name:
Last Name*:
Public Address:

City: State: Zip:
Phone: format (xxx) xxx-xxxx Fax: format (xxx) xxx-xxxx
E-mail:

Reside in Santa Monica*?	Yes	No	No. of years
Registered to vote in Santa Monica*?	Yes	No

Specify current or prior service on City Boards/Commissions:

List Community activities in which you are involved:

Describe your qualifications, experience, and education, and list any technical or professional requirements you have relative to the duties of the LA County West Vector Control District.

What are your goals in serving on the LA County West Vector Control District?

BUSINESS INFORMATION: OKAY TO DISPLAY ON INTERNET*? Yes No

Occupation*:
Bus. name:
Bus. address:

City: State: Zip:
Phone: format (xxx) xxx-xxxx Fax: format (xxx) xxx-xxxx

FOR CONFIDENTIAL USE ONLY:

Residence Address*:

City*: State*: Zip*:
Phone*: format (xxx) xxx-xxxx Cellular: format (xxx) xxx-xxxx
ALL INFORMATION, EXCEPT INFORMATION ENTERED IN THE CONFIDENTIAL SECTION, IS PUBLIC AND AVAILABLE FOR VIEWING AT THE CITY CLERK'S OFFICE AND ON THE CITY'S WEB PAGE (EXCEPT AS NOTED ABOVE).

DISABILITY RELATED ASSISTANCE AND ALTERNATE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST BY CALLING (310) 458-8211