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1400 Terra Bella Ave., Suite M, Mountain View, CA 94043
(650) 968-1540
(650) 968-1543 fax

(Print or Type)

Full Name __________________________________

Address ________________________________________

_______________________________________________

Business Telephone _______________________

Residence Telephone______________________

Present Employer _________________________

Occupation ______________________________

Address _________________________________________

________________________________________________

Years in Mountain View (If applicable) ________

Briefly describe the qualifications you possess (employment, community experiences and education) which you feel would be an asset to the Board. Please use additional sheet if necessary.

List the community organizations which you have participated and describe participation.

I have sufficient time to devote to this responsibility and plan to attend the required meetings if
I am appointed.

________________________________________________

Date Signature