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Altadena Town Council Application Form Altadena Town Council Public Education Committee

The information contained on this form is for the Altadena Town Council to fill not to exceed 21 positions on the Public Education Committee for the 2012-2013 program year. Please fill out the form (front and back) and return to the Altadena Town Council Public Education Committee, c/o Altadena Community Center, 730 E Altadena Dr., Altadena, CA 91001. The form must be received by May 4, 2012. You are welcome to attach additional pages, a copy of your résumé, or submit supplemental information which you feel might help the Altadena Town Council Public Education Committee make its recommendation.

Last Name

First Name

Preferred e-mail

Street

City/Zip+4

Census Tract Number

Daytime Phone

Evening Phone

Fax

Employer

Work Address:

Term of office. I am seeking a one-year term one-year term

I am willing to renew for a second

Children Grandchildren in PUSD. (Please list grade level and name of school and for each child/grandchild)

Grade level

Name of school

Grade level

Name of school

Grade level

Name of school

Employment - Title and duties, current and past.

Community Service - List boards, commissions, committees, and organizations on which you are currently serving or have served, offices held and in what city.

Education Include professional or vocational licenses or certificates.

Please continue on the reverse.

Personal Please answer the following questions.

1. Have you ever worked for the Pasadena Unified School District (PUSD)? (If yes, please

list dates/department) YES

NO

2. Are you related to any employee or appointee of the PUSD? YES

indicate name and relationship.)

NO (If yes, please

3. Rules of law and ethics prohibit Altadena Town Council Public Education Committee

members from participating in and voting on matters in which they may have a direct or indirect financial interest. Are you aware of any potential conflicts of interest which would

preclude your service on the Altadena Town Council Education Committee? YES

NO

4. Have there been or are there now, any personal or business circumstances which might

reflect adversely on the Altadena Town Council? YES

NO

5. I am aware that there is a regular recurring monthly time commitment necessary to fulfill

the obligations of committee service for Altadena Town Council Education Committee. YES NO

6. What would you like the Altadena Town Council to know about your background, training,

education, skills or interests and how they will help the Public Education Committee?

7. What do you think the objectives and goals of the Altadena Town Council Public Education

Committee should be?

8. How would you help achieve these objectives and goals?

Signature

Date:

I hereby certify that the following information is correct to the best of my knowledge.

One of the goals of the Altadena Public Education Committee is to ensure that the Committee represents the geographic residence, location, ethnicity, gender, and age of the communities it serves. The following information is desirable, but not required for

appointment. Year of Birth:

Male or Female:

Ethnicity

Please return this form by May 4 to: Altadena Town Council, Public Education Committee, Attn: Amy Cienfuegos, 730 E Altadena Dr, Altadena, CA 91001