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HomeMy WebLinkAboutAppointments to the City-County Board of Health Commission Memorandum REPORT TO: Honorable Mayor and City Commission FROM: Cynthia Jordan Delaney, Deputy City Clerk Chris A. Kukulski, City Manager SUBJECT: City-County Board of Health Appointments MEETING DATE: May 19, 2008 RECOMMENDATION: 1. Confirm the County Commission’s recommendation of Berk Knighton to fill the joint City-County vacancy on the City-County Board of Health. 2. Appoint one member to fill the City Commission-appointed vacancy on the City-County Board of Health. BACKGROUND: Because of recent resignations, there are currently two vacancies on the City-County Board of Health: one member appointed jointly by the City and County Commissions and one member appointed by the City Commission. On April 24, 2008, Health Officer Stephanie Nelson sent an email that highlighted the City- County Board of Health’s recommendations for these two appointments. Please refer to Ms. Nelson’s email. On May 14, 2008, the County Commission formally recommended that Berk Knighton be appointed to fill the Joint City/County vacancy. Tonight it is the City Commission’s task to confirm the County’s recommendation. Please refer to the documents sent by Crystal Turner, the County Commissioners’ Assistant. Filling these two vacancies tonight will greatly assist the City-County Board of Health to complete important tasks and meet deadlines with a full board. The City-County Board of Health is created under an Interlocal Agreement between Gallatin County and the City of Bozeman, dated June 1990, as amended under the Interlocal Agreement dated May 12, 1997, pursuant to the provisions of Section 50-2-106, M.C.A. The Board is comprised of nine members as follows: (1) a County Commissioner or representative; (2) a City Commissioner or representative; 124 (3) three members appointed by the County Commission; (4) three members appointed by the City Commission; and (5) one member appointed jointly by the City and County Commissions. Members shall serve staggered three-year terms. There is no residency requirement for the members. For example, the members appointed by the City Commission don’t have to be residents of the City of Bozeman. The Board is administrative and is responsible for appointing a Health Officer and ensuring that the necessary qualified staff is employed, within budget constraints. The Health Department operates under the County and its personnel manual. The Board is responsible for activities ensuring the health of the community, including guarding against the introduction of communicable diseases and providing for the removal of filth that might adversely affect public health. There are currently two vacancies and five applicants. All five applicants happen to be City of Bozeman residents. New Applicants: · Berk Knighton (formally recommended by the County Commission to fill the joint City- County appointment vacancy) · Gretchen Rupp (recommended by City-County Board of Health to fill the “appointed by the City Commission” vacancy) · Becky Robideaux · Karen Sanchez · Richard Damon ALTERNATIVES: As suggested by the City Commission. Respectfully submitted, ___________________________________ ___________________________________ Cynthia Jordan Delaney, Deputy City Clerk Chris A. Kukulski, City Manager Attachments: Board Applications Resumes Correspondence 125 126 Cynthia Delaney From Nelson Stephanie StephNelson@gallatinmtgov Sent Thursday April 24 2008 234PM To Turner Crystal Cynthia belaney Cc bvaughn@montanacom Subject BOH Appointments Follow Up Flag Follow up Flag Status Completed Crystal Cynthia The BOH met taday and considered their recommendatian to the City and County Commissions for the joint appointment to the Board of Health Tim Ford has filled this position for many years and recently resigned His term would have expired in January 2009 Five very qualified applicants were considered Berk Knighton 2 Gretchen Rupp Karen Bucklin Sanchez 4 Becky Robideaux Richard Damon Due to his expertise in air quality the Board recommends Berk Knighton to fill the joint appointment position There is a second vacant position that is a City appointment This appointment would complete the term of Dennis Alexander that will expire in January 2010 The Board would like to express their interest in having Gretchen Rupp appointed She would bring a tremendous amount of expertise in water issues Please note the Board is aware that this appointment will be made at the discretion of the City Commission Please call if questions Stephanie Nelson Health Officer Gallatin CityCounty Health Department 311 West Main Room 108 Bozeman Montana 59715 Phone 4065823120 Fax 4065823128 Emailste hnelson allatinmt ov 127 05012008 1023 4065823128 GCCHD PAGE 06 Name f7 Date 2eToa Adclress V IsMSTI AcldXegS ata Ca ac City C1 State 7 dip 3i Phone Dome 4t VVorl to 95 CepOther i 9 33 arc you a resident of Gallatin County rt Length of residency in Gallatin County Hoard or Committee you are applying fvr Ce9lI off CCU1atiOn SiZ uESad2 Ernplcyer 11 T eJr r Se 1iaveyou previously served vn a County or City board 1f so which board and for lorvlong Past McmUerships and ssociations Crrcnt1Vlcmbrsliips anal Associations List any relevant qualifications andor rclatedexperience Attach any additlonai infarmatian or a rsumdifyou t7rer What are your primary objectives for serving pa this board V References Jndividuai or Qrganization SIPetC ScJ y hone 1 5r An inteniew rnxy he requieai if deentied necessary 7harekirrou rrz advance for yait attetst D 128 GCCHD PAGE 07 05f012008 1023 4065823128 lpr1 DO l7eax Stiephanie Enclosed you will find niy applJeation for tlae Boaxd ofHealth in this cover letter T wpuld like to express my interest ita serving on the board and to provide you with some of any qualifications As Iracticirxg scientist inn airpollution reseatch l look torwatdto being able to utiIize tle expertise txatI have acquired in my profesaianal oareer to the conuxunily where l live 1 believe tiaat T will briixg a belancedyet irtfor ned approach to this positigil lerelaticnslai ietvveelhuman health azaI aut evircnnzazitxs complex and iotalways easily defaned This opporiuttity also benefitvq me as it allows meto expand zny knowledge on lXOw enviroaxnettalpolicy is implezxented i look forwaxd to scving nn ilehoard atd Iearni3g fiyom the othez experienced inairbers Below is list of rny ualihcatiois I38 Clemistxy Molatana State University 1978 1VdS Ihysical ChEristry Montana StteLJnivagity 198 IhTaAnalytieal Chemistry Montana State University 1 984 Assistant Professor of CheanistyFrarilclit and Marshall College 1984 1987 Pesearch Associate Montaua State University 19871991 Associate lescaxchIrafessorofChemiatryTvIontsnaState University 99 17x5e1lt Tlight 17ireator and Faculty Advisor for the BC1thTISPugh altitude balloon program Physics IcpaxtmextMontana Slate Uriversity 2006 present Research Interests iaa atmaspheric science and aar pollution Mezaaber of art international science team 2002 20D3 sad 2Ut16 tlaat studied air pollution lt lYlezico City Advisor to ileFAA and ElA ova the chemical comporands emitted from commecialjet aircraft engaines Sincerely yours f l3erlt Ktightoi V 129 05012008 1023 4065823128 GCCMD PAGE 02 f iVataae Detc 1 0 y J s AdLI il Ti Addres5 1 City ICJ f11r1 5tatp i Phase 13ome VVa1t CellOther Aro you aresident oC3allatin Cbtxirty 1ai to said il County natd or Corqitveu aapplyixr for t1 C7cCUpation f Ea Nave you fieviouslysoivacl an a Coun ar C y bti d C17W1 a W1 A1sowlacl board acid for how lqu G 1 ti A ra r troc 1ren 1i Currant lWlezubars sand gyp dKJL Y IIr1 Tit rclevant ualircatiatrs andor relaedexperience1 Attach airy additional infexmti4xr raresume ifyouprelbr Wltat ara your prim objCtiv for servitltig on this bord7 r kJan 1tQtrces dividtral p xganizatanrx Phone P1aA11e r4 tervirMr 6ered deedn Tl iadvaly r fM 130 05012068 1023 4065823128 GCCHp PAGE 03 kvvxars muvA91VAwAexClN11 jov2 GfiRlwfcR tBNGT11fE GfCrAPL RLlf berrirlcF 7a improve the natural and human environment through the successftal management rrfsaencra and enginaelring programs adhering tv the highest degr pftechnlcsl rigor EauCAT1CI NiS GivA and nvlrcmmentai lngineeRrgUtah tte iJniversity I 91 EIA BiQlagy CaHetvn College 6 cum laude uvith departmental honors FROFESSiQNAiREISTTIQN Professional Engineer Montana iioenae1fi0 PE 1gltlProfessionalCivilEngilerrrtlifomiaIicenC3705198 AFIiiATiC1NAiDSEfViGf Member American Wafer Worsts AssrciaiAn Interttatianal Warer Asaciation American Water Resources Assocltlon President idativnal institutes for Water ResoUrcas 21JD57E3pardmemberUnlversfesCCuncilpn1NeterReSaurs2003PresidentMontana5eclranAVtIC41i9ti7 PRCIESSiDNAi EXPEIiE11 QQti preeenii airearIVrrtanaUniveity Syrstem IIfrGehtar Illiarttana iteUrtiversityRespdrrslbiefortheoperationotagranfrlndedresearchanddutiachorganlzatitnwithupto40 employees an aquattc saianras laboratory and an annual budget of3 million Frinclpal programareasawaterglalitysmallwatersystemsfisherieshealthandaquatiahabitatS bttrwater ntermnntanaedu 992Qt1Adjunct Asaaciata Prataar ofwiilngineertng Ilntanaate Unireraly Appointment dialled among the Monane1NrCenter the MSU Factensivn Service and the department ofCEvN ngineermg Saraed as V11eterCenter Assistant L7irecarand managed the Small Systems TechniC81 Assistance Center averseein9 mare than 2frll9Caiedemansations Df innovative treatment technvlogfeus at pubilr vaster eystems As Extension Environmental 1nglneeraetlasconsultanttttengineerspublicworksdireetcrsandMontanaoltinsanissuesofwaterand wastewater treatment water quality livegtdclc wastes air quality and solid and hardcuswastesDtranizedprofssionaitrainingcursesproducededwratianalmateliAlamedQpresentatiCIgscrv on oversight erxmmlttees responded to requests fps irfarmetionpr aesistanae As Civil Engineeringfaoultymembertaughtenviranmenfalrngineringandadvisedgraduatestudents r 131 05012008 1623 4065823128 GCCHD PAGE 04 99813 X1394 IndepenntfrrvimnmeniCotwsultanBrmn Montanea crganiiworkshape an tadioaCtiv wtt soil sampling anti hardauswaste characterizatian and edited the pruceedfngs coQrdineted bblcgicabaseline studies far Matdmck mining served es technical adviser to businesses and Communities with hazardouswasteateliability pnapared guidance dacurnents an oil and waste Cftiaracterizatitnand soil tratapliYtesting at Bupetfund sites Clients induded the Gitypf Livingston Mrantr3ne the US ErrtirorimentlWrrtectfanAgency StillVvater iVlining Company nd the Park purity Environmental Cpaiition 191ST 1988 SenlarrtlirOf1111ElitalEngineer M51 prtoxiaatiart 1nC Bazernan f1Markana larojects included environmental site assessments development pfsite sampling and waste treetmeM wprkplens and managing tMe vrsgetation and runoff investigations of the ASARCU East Helena SuperFund invsstigatlori 999 m 9987 Staff Environmental Engineer TetrlTech inc lataayettefaalifarnRa andf Butte IiJicrrtane Golerteddete perormad technical evaluations end prepared reports ccancerning wastewater discharge elecia utility solid wastes leaching cf oQai fly ash and sorubbar sludge and the envirannyental irrlpacts ref Midgetman mislls deployment In Nlarrtana falrelopedcalculation mGthrads far assessing pollutant bahetior In the eravirtanrnant prepand guldanre documents taught water quality asseasrrien wprkshops Salved as project faidloglst In evaluating effects Gt hydropowar development on montane fish habitat Managed the field caffice slid inVestigaticins 1pr the Anaconda Smelter Ierrrediallr7vestlgetian Ciicllts included the Electric power Research Institute the US Ernvironmental Prptectlon Agency Pacific Gas Electric ARGO Arid tMe Airiarse 19759J81 Graduel lsearchA3eisrlt Utah Vuaker eseerch taiaoratarryUtah State fMnlversitrExamined the Influence rxf benthic periplytan an tfte geochemistry ofrnnntane streams Thesis titie trelcium carone prcipitLafarias nfluencedrrystream primary iatducfilorl 19761978 Staff Blvlogis Bennuda Biaiagtcai Statlon St GeorgaWest i3iRMUdA Planned anti COrldUctad studle refthe distribution ecology and physiology of nuisance aiget in shellowinshore wetere Participated in steadies defining benthic marirle cammunitles grid water quality by field sampling aeriai phtatCtgraphy radiatracaC exprrimenslabarartary analysis send rigta interpretetlan fSEARCFl AND lUTREAfhl Siraae 2Q00 mare than 5pX10 tntsrindustryprpfesslandlr3 especlgily personnel pf small public water Systerl1s have used the interactive training Courses developed by the Montana INatar Cenfier rseW f1tt0wtercerrtercntanaedufirainirrcldePeuithtm fecentgrantfunded nseard7end outreach h concerned the health afaquatic econysems rnded lay the US Fish Wildflfe Service Mrantene Fish Wifdlife 8 ParkrA U9 Environrrrerital Proteakion Agency and th State of Moriterre smai public water systems fPAand Agrloulture Canada water lint corrosion lritematianal Ccpper Asscaclatkn stcrmwater cvritrpl EPA ald the Adpntana QEC and vuetlends education EPA SELiCTEG1PUBfIGATICI18 ANp EX7ENSit1hl ilJiLITN Butrerfleld PW A ICamper and C3L Rupp Q0701llirletool helps utlRtieFs assess mlcctaial cantaminaiarlrisks Opflorv 331 04 Rupp page 132 05012008 1023 4065823128 GCCHD PAGE 05 vtmivLAruAf1AlK lltiN1Lki i00 Rupp GL and G Bdttn217p8 NorkhwetWetar Policy Law symposium lrsliCyWhits paper CIlpntaneState 1Jnlversi hLwetercentrmontane IuloslfJiZte oener Adt Rupp GL and B Cichokf t706 Rainwrdter lianrestin Syslfnsfor fltantanaMnntdulde 970 MSIJ tension Service f3ozemtan MT 5 pp httbwwwmo0neduwrnrvvnbhubsm49g97aThtnl Fond T D Fupp P uttefelrJ and A Camper 2Q05 Prtrlacdng FudllcHealth Fh tasi Water Systems Report oferr IntemetlatalColloquium Montana Water Csriter cemanMT tt waterrrner nontara undtscxxllogsiumreport rtlvdf Rupp GLand M D White editors 2004 Proceedings ofthe Infernstlanal 3ympsumon Fish Physiology Toxllogyend Meter CualiTalllnrt stvnfd May 1 15 Ci3LJS BRA coBystemsResearchdivisionAthenaA1lAlsonIR041049350pphttolwatrmdntenaedulosiumpraceedinsl Rupp GL 2Dd171ie challenges o inetalfing innavatlve treatment at small water systems JQmalof EnvironrrermelHealth f41r 2225 Samet J Ilrt Araya rskerH outer J f7onohue J Folund K Hellemann a lago G Rupp 2070 ACUe Gestrvlntestlnal Ectsof Copperln Ddnkl Weler Methods for CondtctngRuhllC Mealth Iniresbgatlons May 20U05chaol ofPublic Health Johns Hopkins University Baltimore Md 12F pp Abdo tS t3 Kellar and G Rwpp 1999 ion ehangeand flushing for copper corrosion contnal In small public water systerr PlviceeclingsaP t11 Americn Water Vllorks Asscacfation Annual Canferance rhlcaga IlllnoPs June 22 199 A1AfWA Qenver CQ aupp C3L 996 VVatrCqnaarvatipnfrrr Montana tommunitfesMSU liartertaion rvica Boaeman MT 18 pp Rupp GL 1996 Patlutian Preventiotl and Ptreptmentfor PubllciyQvmed Treatment Works fepvrt prepared for LAS nvlronmantal Wnateckipn Agen tegionVlll MSU Extension Servical3ozcman MT Rupp GL1996nsrbeWastewater Managment Options for Montana Businesses NISU Cxterslan SeniBulletin EB 136 Baseman MT B4pp Rupp G L editvr 1994 Gherackarizing CorltaineredMiI Lowlevel Waste for TraatmertUB rPAOffice of Research and L7evelopmant US Dapartrrntof energy 7ffica of Technology Ivelopmenf EPA840R91148CrtrforEnvironnlentai Researoi1 Information Cfncinnatt ON Fupp G and R Janes edltor 7983 Heteiageneaus Wastes haractatlzatlan lwlethods and lecorrfinerdationsGROPublishers l3cce falrmham 144 pp Rp pege 3 133 wellne scommuntymoniano cancer upporl educollon and hope R YID APR 0 4 208BeckyRobideauxexecutivedirectore 1820 W Lincoln ave bowman montane 59715 ir phone 40b521b00 fay 40658252Z jEmail tWCmantanaQgwestnet ithews omm mo to A T Name Ip i Date Address EMailAddress d GurovfcivtcwC City State CL Zip l Phone Home 0 2 ate Work 2 v CSTj CellOther Are youa resident ofGallatin County Length ofresidency in Gallatin County te Beard or Committee you are applying for Iorxc Occupation C Employer r t cr Have you previously served on a County ar City board Ifso which board and for how longMembershipsandAssociations Current Memberships and Associations List any relevant qualifications andorrelatedexperience Attach any additional information or apreferrwienDvwln 1 ifyou What are our rimyp ary objectives for serving on this board Cf References dividual or Organization Phone J Z 5 Phone c D Phone d w An interNieiv may 6erequired ijdeemed necessaryT1krirg in advancejaryour interest 134 APR 2 3 p0 APPLICATION FOROARDSAIYD COMNIITC1ES Name D Date AddressOL7E1 rRyllEMailAddress rc h o1 r 6 SIB 1ef CityLZOVI State M1 Zip 971 bane Home rj b2 dark CellOther 7t Z l7 nC1 Are you a residentofGallatin County Length of residency in Gallatin County Er Board or Committee you are applying for L C L Occupation l C Lw C7a2 Employer CTUE YtJN7MJ SSd Have you previously served an a County ar City board lr N M11 l3dFl If sa which board and far haw long Past Memberships and Associations 4 d D Fi1R1 S O Current Memberships and Associations 11 fcpf fhM rL D List any relevant qualifications andlor related experience Attach any additional information or a resume ifyou prefer ESUY1 S L13M71 What are your primary objectives far serving an this board lL UV111LtrtIU1ti I N E IIJ I rlr A ilcFitcM D E Vl tl1V R7iDri9 f References individual or Qrganization R Ds iNNa hone 7 w41 z 17Prti9 K7iJG Fhane 3 D V IA N E E R Phone J I J fln iretervlevuy be reruiredff deenerlrrecexsnry Trarrkirrgyott rt adiaceforyottr interest 135 65012008 12fl5 4065823128 GCCHD PAGE 02 April 1 20OS Ta Stephanie llel5on 53 5 h Are Bateman MT 5975 From gpchard A famon iVl B Golden trout Way Bateman NpT 5975 Dear IVps Illson Brian Leland and p first rnet at the seminar given by Dr Stephen Bezruchlca at Ferarras restaurant Qn 11arch He indicated during our shcrt visit the Board of Iiealtlanticipated two upcoming vacancies kle advised that l send him some information regarding my interests in health care and past experiences vthich l think he has sert an tv ycau He contacted me severe days agn advising i get in touch nrith you about interviewpng as a candidate t fill cane of the vacating positions on the Board of Health p retired frarri active medical practice ikt 2Q and moved to lpantanafrom V1iscQnsin In 2uo ZC1D7 my wife 29 years as kindergarterw teacher dpd voluntary medical clinic nrark and tutoring of school chipdren in laimapca thrcaugh a charcl program UUe also have mentcred inn the Pta program and were previQUSly financial counsepors far LQF Ihf Three years ago I gave a one hour presentatiar to p1St premad students an physician patient relationships 1 will be happy to forvrard copies of my active Viscarrsin rnedpcal licensure llD degree Board certiicationand any other documents you may require for validity of my credentials irb addition to the resume sent to Brian Leland My wife and I plan to be rautof state fram April 4 till lpril i8 If you have an interest in givKng me an appointment far an interuier miter t return I would appreciateDearing from you Sincerely Rpchard A Damon kriD 40655094 richanraa bresnannet 136 05012008 1205 4065823128 GCCHD PAGE 03 Richard A 7amon MO Am Beard of Family Medicine Am Academy of iFamily Rhysicians EDUCATII Iowa State College Antes lorna BS 1952 Univ Tertessee Medical School Memphis Tly Teaching Fellmwship Anatomy Histology Embryology Univ Iowa Medical College lows City lA MD 1957 MEDICAL PRACTItF St Beyedictshlaspital cgden Utah FiotatirgInternship x958 US Army Commanding Gfficer fixedMedical Facility Warms Germany x9551961 Univ of Michigan Health Services Ann Arbor MI 1961962 Family Medicine VlaupunUII 19621963 Family Medicine Medical Associates of Beaver Darn group Beaver Dam1Nl x963198a 137 05012008 1205 4065823128 GCCHD PAGE 04 Family lVlediclne RA tarnon MI SC solo 13171Jarren Street Beaver laarn Utol 19811991 Formulated Family fBedicineDepartment Founder of ftortlShare Medical Clinic Door County fVlemorial Ffospital Sturgeon flay ll1997m00 Funderof Open boor Community Clinic free clirpic Sturgeon Balr1111199ZOOU PRaFES51OhIAL ORGANIZATICIPVS American Medical Association IIisconsinState Medical ASaciatior American Acaderny of larnflyPhysicians AAFP Christian Medical and Dental Association Arnerican Academy of Disability Evaluating Physicians SPECIALTY CERTIFfCA7lOACS American Board of family Physicians ABFP 1970ZO2 PROFESSfUNAI ACTIVITIES Chairman Child Protection eam bodge County1M1195519fifi Specialty Training National Center far Child Abuse Denver CCe 1958 Physician Consultant HICFA 19I WISPRO Consultant to Assistant Attorney General Sanction proceedings Physician Consultant fo Inlisconsin State Department df Licensue 19581894 legal Case reuierrrs 138 05012008 1205 4065823128 GCCHD CQNAEREIVCE SPEAKING ACTIVITIES Area Medical Conference US Army Europe Weidelberg Gernnany rganizatinand peratian fa Fixed Military Medical Facility Conference an Regionalization of Perinatal Health Care Chicago li March 1975 lteclucingPerinatal Mortality in a Rural Haspitai Setting APPCINTMIEhGTS Director Beaver Dam Community Hospital Board Beaver Dam WI x9871991 Director Lutheran Hrspital Board Beaver Dam WI 1968197Q Director Door County Memorial Waspital Board Sturgeon Bay IAl19942DDD PR0IESSICDNAL PUSITIONS Chairman QBIVewbornCommittee Beaver Dam CrmmunityHospital EeaverDam WI x9671977 Chairman Utilization Review Committee Beaver Dam Community Hospital Beaver Dam VII 1953199 Chairman Quality Assurance Committee BaverDam Community Hospital Beaver Dam WI 19891991 Chairman Ethics Committee Beaver Dam Community Hospital Beaver Dam Wl 199D1991 PAGE 05 31 139 05012008 1205 4065823128 GCCHD PAGE 06 Chairman 11Iedical records Committee Beaver loam Community Hospital Beaver Dam WI 19911994 Memher Pediatric Committee Beaver Dam Community Hospital Beaver Dam 1A1 19801991 Chairman Family IledicineCmmittee Beaver loam Community Hospital Beaver Dam Wl 1995 Committee member 1971991 President Medical Staff Beaver Dam Comrotunity Hospital Beaver Pam1APl1994 President Medical Staff Door County Memorial Hospital Sturgeon Bay WI 1997 Chairman Medical Ethics Commmittee Door County memorial Hospital Sturgeon Bay WI 19922000 Wisconsin Professional Revienr Qrganixation state 1NISPRQ NISPRQ Utilization Review Committee 19521955 WISPRI Svathwest Regiortal Committeel921985 WIPRO Reviernr and Intervention Cammittee19881991 Assistant Clinical Professor of Family and Community Medicine Department of Family and Community Medicine Medical College of Wisconsin Milvvaukeelhl19977000 l 140 05012008 1205 4065823128 GCCHA PAGE 07 VOLUNTEER POSI1NS Consultant LV INC Bazennan MIT 20032005 1llentar Childrens Advantage Progranrt CAP Emily Dickenson Schaal Oozennan SPIT 2004007 fueclical 11llissionlartaice 00 Irledical 11lissivn aarnaica 2006 SPECIAL INTEFdESIS Health Care Refarm Issues Fly Fishing Skiing Hiking Piano 141 04232008 1191 FAx 406 5B6 2566 USdA Rura Revslnpment AfiR232008 WEp 1008 Ahf GLTN CNTY CQMPtISNRS pX ND 4Q658F3003 Gallatin County Commfssian 311 Went Main Sbreet naeman MT 69715 raoao2 P 02 o Adcitesa p10 AN l UMsilAddvss City States P G q rOL Plaonc Hama 5 Vcxln CelUUthr Ara you asesidentofallatits County Letgk of residency iu Gallatiu iotmtyv oaddr Committed YOU for Gt7tGa 93vDYfdTt Occupiou tV 1 tFL 1 EZ ILkuw4z C JVtinIT Emp1Oyer v Havel yom pviovely Served ate a County ar Clty bcaed7 Tf ao wvbich 1oaad and hnvrQa pest Mrnabdrslipsad Pissoaiatiane CeeatMeaabeips sad Associate JJG4iV1 vJ0 C WA 1u1 fiJULikSSvG List any relevant uns andor relatad de Atc1i a1y additiorael intomcnatiau ar a rdsuai if yap Pry t c w what ere yoarptunaty abjdvesfor prving onthis hasrd 6 Ttcferances ndividuel ar Crgauiaiaa JVI u11fRGlat1v1Cs CouNGlLhanrN1t1 M oV W Ind P9wna r u L1SlOi Are arvkw may be regWtsed fdated ecsass fJjaFOlI OI1Cls fpT y0itr C 142