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CITY OF SAN LEANDRO - GENERAL PLAN ADVISORY COMMITTEE (GPAC) <br />APPLICATION FORM <br />PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION. ALL INFORMATION WILL BE KEPT CONFIDENTIAL. <br />Nl` '4E: <br />ADDRESS <br />PHONE NUMBER: <br />❑ Check here if you would like to receive future mailings about the General Plan update. <br />DO YOU WORK IN SAN LEANDRO? ❑ YES ❑ NO <br />IF YOU WORK IN SAN LEANDRO, PLEASE PROVIDE YOUR WORK PHONE NUMBER: <br />WORK ADDRESS: <br />THE FOLLOWING THREE QUESTIONS WILL BE USED TO ENSURE THAT THE GPAC /S BALANCED AND <br />REPRESENTATIVE OF SAN LEANDRO. THESE QUESTIONS ARE OPTIONAL. <br />WHAT IS YOUR AGE CATEGORY? (Optionan Please check the appropriate box. <br />❑ Under 18 ❑ 51 - 64 <br />❑ 18 - 35 ❑ 65 or older <br />❑ 36 - 50 <br />WHAT IS YOUR GENDER? (Optionan ❑ MALE ❑ FEMALE <br />WHAT IS YOUR ETHNIC BACKGROUND? (Optional) Please check the appropriate box(es). <br />❑ White / Caucasian ❑ Native American <br />❑ Black / African — American ❑ Asian / Pacific Islander <br />❑ Hispanic / Latino(a) ❑ Other (specify): <br />PLEASE TELL US ABOUT THE GROUPS AND ORGANIZATIONS THAT YOU ARE A MEMBER OF <br />MARK IN THE BOX NEXT TO EACH TYPE OF GROUP THAT YOU BELONG TO: <br />❑ Faith Community (e.g. churches, temples, etc.) <br />❑ Service Organizations (e.g. Rotary Club, Soroptimists, etc.) <br />❑ Non -Profit Organizations & Service Providers (e.g. San Leandro Hospital, Girls Inc., etc.) <br />❑ Business Associations (e.g. Chamber of Commerce) <br />❑ Transportation Organizations (e.g. East Bay Bicycle Coalition, etc.) <br />❑ Development Community (e.g. real estate, construction, land development, etc.) <br />❑ Educational Institutions (e.g. schools, colleges) <br />❑ Environmental Organizations (e.g. Sierra Club, Greenbelt Alliance, etc.) <br />❑ Cultural Organizations (e.g. UPEC, San Leandro Art Association, etc.) <br />❑ Neighborhood Organizations (e.g. homeowners association, etc.) <br />❑ Recreational Organizations (e.g. sports leagues, etc.) <br />❑ Citizen and / or Resident <br />❑ Other (specify): <br />PLACE A CHECK <br />THE GPAC WILL BE IN EXISTENCE FOR APPROXIMATELY 18 MONTHS. MEETINGS OF THE GPAC AND ITS SUB- <br />COMMITTEES WILL BE HELD MONTHLY, MOST LIKELY IN THE EVENINGS. DO YOU FEEL THAT YOU WILL HAVE THE <br />TIME TO ATTEND THE MEETINGS OF THE GPAC, ITS SUB -COMMITTEES, AND OTHER RELATED MEETINGS? <br />❑ YES ❑ NO <br />ARE THERE ANY CONFLICTS OF INTEREST WHICH MIGHT PREVENT YOU FROM FULFILLING THE DUTES OF A GPAC <br />MEMBER? IF YES, PLEASE EXPLAIN. ❑ YES ❑ NO <br />Reason: <br />USING ONLY THE SPACE PROVIDED, PLEASE EXPLAIN WHY YOU ARE INTERESTED IN SERVING ON THE GENERAL <br />PLAN ADVISORY COMMITTEE. <br />ontact Kathleen Livermore (577-3327) at the City of San Leandro if you have any questions. <br />FOLD FORM IN HALF, SEAL, AND MAIL. FORMS MUST BE RETURNED BY FEBRUARY 5, 1999. <br />6j <br />