City of Culver City, California
City Council Agenda Item Report
RECOMMENDATION:
The City Council is requested to appoint members to the Disability Advisory
Committee (DAC) for Office Numbers 1 and 5.
BACKGROUND/DISCUSSION:
The Disability Advisory Committee was established by the City Council in 1985 to
advise the Disability Services Specialist, the Senior and Social Services Division,
and the City Council on issues relating to people with disabilities. In 1990, the City
Council expanded the committee to seven members.
Currently Office No. 1 is held by Christopher Brown, who has expressed an interest
in continuing to serve on the DAC.
Office No. 5 is held by Jay Shery, who also has expressed an interest in continuing
to serve on the DAC.
There are a total of three people who have applied for the two offices up for
consideration.
FISCAL ANALYSIS:
There is no fiscal impact.
Meeting Date: 6/12/06 Item Number: A-4
AGENDA ITEM: Consideration of appointments and/or reappointments to the
Culver City Disability Advisory Committee.
Contact Person/Dept.: Camille Jones Phone Number: (310) 253-6729
Fiscal Impact: Yes [] No [X] General Fund: Yes [] No [X]
Public Hearing: [] Action Item: [X] Attachments: [X]
Public Notification:
All Candidates (6/6/06); Disability Advisory Committee (6/6/06); Master Notification List
(6/7/06)
Department Approval:
William L. La Pointe 6/6/06
CAO Approval:
Martin R. Cole for Jerry B. Fulwood
(06/07/06)
City Controller Approval:City of Culver City, California
City Council Agenda Item Report
ATTACHMENTS:
1. List of all applicants
2. Copies of all applications
MOTION:
That the City Council:
1. Appoint ______________ to fill Office No. 1 as a member of the Disability
Advisory Committee for a four-year term expiring on June 30, 2010; and
2. Appoint ______________ to fill Office No. 5 of the Disability Advisory
Committee for a four-year term expiring on June 30, 2010.
MEETING DATE 6/12/06
AGENDA ITEM Consideration of appointments and/or reappointments to
the Culver City Disability Advisory Committee
ATTACHMENTS
Pages
1 List of all applicants
1
2 Copies of all applications
2-15ATTACHMENT 1
DISABILITY ADVISORY COMMITTEE
List of Applicants
Name City
* Chris Brown Culver City
** Jay J Shery Los Angeles
Robyn Tenensap Culver City
* Currently appointed to Office No 1
** Currently appointed to Office No 5
IATTACHMENT 2
RECEIVED
2006HAY
30
PH 2
03
CIFY
LI_Ekh
CITY Cln
APPLICATION AND BIOGRAPHICAL DA.TA OF
CULVER
FOR COMMISSION, BOARD OR ADVISORY COMMITTEE
MEMBERSHIP
(pictise typo or print)
CITY OF CULVER CITY
J770 CULVER BOULEVARD P 0 BOX 507 CULL ER CITY GA 90232 0:207
[ he infoimation untrained on this form is for the use of the Citv Council in order to rill VilLeLENALS oo
Cu) C °mint st otib Box& Advisory C ommittees p i [ask I ni ces HoRever all information on this
form will bet ow d iiiibht mord and he avrnlablc to. nubic inpcxtion or do licabon as
authormd by law
Separate applications must be subnutted for &Kb body to sl hid] applluition iS bemg made
General Information
I Identify the Commission Advisor} Commiltct or Iisk Folt,e to hih appointment is desired
62. 1 64, ea.- °AY 4 6 C.47 7 vics ort7 6, mei- '11/Pe
If applying for a position on he I !anti-A mini !Julia! um Build inchoate whether ) ou Arc
app134ng as a tenant represent iv ( landlord npri-sc-rnar v ( ) al member at huge
representatrve ( )
Call the liaising Di % rstoi it (310) 253 5780 ir roti hive my qi.I ‘licinx resardeng eirgilmht) for Undlo-cifTcrtuit Me4114tion
Board pohitionh
3 Name Arvtc
greywr,
Tkphon
Addrvss 71p fe05 z •
Eisme.s,s, 64- Trk,phont. ( ) Address
Zip
F mid iddrkss .-4)?iver rite joiletwirat! (tl additional Om ell ?plot Li.s(ery)
4 Community Service
(LIM hoards Lorrimissions, .t.ominittees and organizations on inch ou have served or trinntly
sei ve, offlts hiAcl and ril fiat (Ay )
t,t, Cd-r
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C.' ,unta Ernplo,ees rake pritfo orectrvely providerig ie h allt6.54 Sell Joe to enach the qt,ahly of life for the crm'nflrb y hy barking . on our
'rad t on of more then seventy nee yemrs of pubfro sem co by our presertt commtmort arid hy our deck-Mon Jo the cliabenges o f tho ft. rtre
n1'rmrH p ncv— C171 r
pz.Page 3 of Application
rni, h r fl,„( t ackt.rst.1) on t h k. proprkty of your bur, ing tV)a rnanb,r
ol any body Lo which you miL,ht be appoinit.d9
15 From, in inv matins of thz. Comariwon Rodrd or Cornrnicy. . 10 whiLli you are interested in being
appointed have you attended in the last year" 2-
16 How much time on a monthly basis do you anticipate. spt.ndln,, on prtparat ion foi and attendance at
meetings of the body to htch you desire appointment'?
/
17 Why are ) ou interested in appointment to a City Commission Boat cl Committee or Task Force'?
d IA/ i7k
fa vse red'
W/
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a .67( s fife skte.e.e /-r)
18 'A hat is tlica, sp,clfically in your background training education or interects which qualifies you .1.5
an
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e . t re-z, e-44--45) Ar kve-a 4C 110{1- 15 i/Ny
20 How ouid ) OU rt Lotnrnend ih objLetises and goals of the body be chang‘d or angmented9
ei ,Crrie-gd4, Cee ,--40
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21 How would you help achieve the body csttiblisliLd obiettivLs and goals'?
ete2/C. -C
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PIIINTED UN Fit CYCLED PAPcn
(9 What do vu see as the objecus es und goals of the body to win( It ti011 a Lk appointinont
3,s, Mew?
6---4
Page 4 of Application
""),
V hat speLial qualities can you bring to the body to which you seek appointment')
Rer-v/e63-e eae,a4
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RLMINDER All information on this .inpliication wilt become a pubbc record Ind ho alnalable for
public inspection or dunk aiiion antborired by law
I hut eby certify that the tangoing information is Larrect to the bi.st ol my knowledge
Signacuiee 5.` IS t 06
You lit. invited to attach additional pages enclose a copy of your resumt, 01 ubiiut supplemental
in I orm ilinri which you feel may assist the City Council in Its evaluation of your applic
Submit appliLai )11(.) and attachments to City of Cub, Li City
kitenuon City (Jh.rIc
9770 Culver Boulev ard
Cuhei City CA 90232-0507
(310) 253-38 I
On ION &IL
In order to assist tlic City Conned in suling to balanet. appointments in tei ins of geogiapbic lotion of
iesidence andloi busini.ss c thnieity 1,entkr iiid agt. the foil 0 4 mg int onnation is. desirable but not
eq no ed for ippl lc au on mibmiss ion or appoini meat
If a City iesident for ho long 9 2-2— Y rA 6-11- a ( ity business ov.ner/opetatoi foi how long') Male A rc Femik. Ethimity in, r41-17-e"
s,L)51b,
PRINYFP RE-Y' ED PAPER
Year of BirthPage 2 of Application
5 Employment
(Title and duties current and p tst
6 Education
pr/1112irina1 or y ot.atio n al ltcLnses and certificates
6;4 6//
cw,s, 4, v
, r-7157 Ze e. A 910)
Personal
7 Are you i U S
8 Ire you iegistered to %me in Culvei City
YES 5‹. NO YES ><' NO 9 Have you ever been convicted fined impusoned or placed on YF 3 NO X
probation for a lelomoi foi a misdemeanor involving fraud?
10 Hat. you evei worked for the City of Culver City (If )s list dates and YES nams of departments )
11 Art. 3, au idatt.d to any cm lent C it y employ.ees or appointees of the City YES NO of Cul yt r Co (If vs indicate name and / elatianship )
12 Are you avt.ark- that financtal disclosuie may bt rcquutd annual Iv NO
(e g sources of income, loans and was innstrimiis iniciLsts in teal
propilty )
b Rules or la y, and ethics piohibit members from paimipating in ad YhS NOX__
voting on matters in which they ma Y have a ilirt.A.t in indirect finanLial
interest Art. you aware of any potential conflicts of inttrtst whiLli may
develop from your occupation or financial holdings in raition to your
re qponsibilitiL q as a membei of the body to whit1 you st.i,k appointment
(It ec please indicate any pott.ntial conflicts )
H L II1LIL bLen 01 °AL thete now any business cirt.timstain-us hii.h YFS NO X."
PRINTED UN REVYC,LcL)
52006 HAY 19 P1112
29
RECEIVED
APPLICATION AND BIOGRAPHICAL DATA CI TY CL
FOR COMMISSION, BOARD OR ADVISORY comitivritruE
R Cu I
MEMBERSHIP
(please type or print)
CITY OF CULVER CITY
9770 CULVER BOULEVARD P 0 BOX 507 CULVER CITY CA 90232 0507
Me information contained on this form is for the use of the CM Council in order to fill Yatanuts on
City Coninussions Boards Atkisory ( °millraces a I isk 1oices However all iniciimation on this
form will beiame u iiublrt meord arid be available tor nubile insptction or duplication as
iiithormid b% law
Separate applications must he submitted for eath body to which application is being made
General Information
I Identify the Commission Admix) . Commatti, or Tisl Fort.e to 441101 appointment is &sired
DisaBility Advisory Committee
It applying for a position on the LandlOrrirrt 11(Mi hfcdiation Board, indicate whethei )ou die
appNing as a tenant representame ( ) I indlord rcpri-scrriallve ( ) oi member it liige
representative ( )
Call the FloLstng DIN ism-) it (310) 253 5780 It you Imo an) queoinnx !turtling eli giblitt) for Luitilordifutu iNtodiation
Biwa pmitions
3 Name Dr Jay J Shery Tt-1(phont.
90066
Addmss 711) Business Tcltphont,
Address Zip
90232
F-mill idctress
11111011=11111=11111
Amity, r r he filliniong ((f mammal kitzteR if nu ci Vary )
4 Cominanity Service
(List hoirds unrunismons committees and organizations on %%hich you have served
stave officLs had and HI %%hut ) Disability Advisory Committee 7/01
Chairman D A C 7/04 — 5/06
Representative toCDBG Committee
Eychange Club of Culver City 1992 —
President 2004-2005
OF („tirrentlY
5/06 Culver City
2003
present
C.:orieer C ity Employees fake pride m offectevely provideng Ole h dfres1 ievels sen jcv to en»ch rho ca,ahly of life or the car nmurn y by bulidiqg on our
'fad f on of more than severrry live years a pubIrC sertko by ow presort! commitmont and by our deoSe.fflon /0 moot11w challenges of tht. V*
rrprracil pr r0 I Pr/ r
G.Page 2 of Application
5 Employment
(Title and duties, current and past )
Media DistrictChiropractic, Owner Clinic Director 1986 to present
Law Offices of Heisler & Bray, Attorney, 12/02 to present
6 Education
(incluck, prok.ssiondl or voLational ItcLnses and certificates )
Loyola Law School J D May 1999
Los Angeles College of Chiropractic, D C 1986
Upsala College B S 1977
Personal
7 Aie you a U S citizen" YES X NO 8 Are you registered to vote in Culvei City YES NO X
9 Have you ever been convicted fined imprisoned, or placed on YFS NO X
probation for a felony or fat a misdemeanor involving fruid/
10 Have you e‘ei worked toi the City of Culver Ctty 9 (If yes, list dates and YES NO X
names of departments )
X
11 An, )uu iLlatcd to any cut rent City emplaces or appointees of the City YES NO of Culvtr y9
(If vs indicate name and 1 elationship )|1010|12 kre you aware that financial disclosure may bt rupuriA1 annually ) YES X NO (e g sources of income, loans and gifts invtsitnotis iniLitsts in teal
properly )
11 Rules or law and ethics piohibit members from partiLipating in and Y FS NO X
voting on matters in which they may have a dirt t.t or indirect financial
interest AD. ) au aware of any potential conflicts or mtuot which may
dnelop from your occupation or financial holdings in alation to your
responsibilities as a inembei of the body to whith you sui appointment?
(It yes please indicate any potential conflicts )
14 H i i. theic IlLen or ate there now any business ircuinstanc-es which YFS M) X
PRINTED UN FitCYGLW PAPER
7Page 3 of Application
might rfl advcrscly on thc proprit ty of your st rung 4 in rtiber
of any body to which you might be appointed')
15 How many mu tings of the Commismon Floard or Committee lo which you are Interested in being
appointed have you attended in the last year 1007
16 How much time, on a monthly basis do you anticipate spcntlin o on preparation foi and attendance at
meetings of the body to which YOU desne appointment'?
I anticipate spending an average of 5-10 hours per month on activities
related to this committee
17 Why are you interested in appointment to a City Commission Boaid committee or Task Force'?
I have served on the Disability Advisory Committee since July 2001
and as chair of the committee for the past 2 years It has given me
an opportunity to give back to this great community We have seen some
wonderful changes in the past 5 years, and I look forward to serving for
the next 4 years,
18 What is dim specifically in youi backgiound training education or interects hieh qualifies 3cu as
an ippoinict,9
In the past 25 years of my professional career, I have cared for patients
with various disabilities I am trained and certified as a Qualified
Medical Evaluator by the State of California I have always been an advocate
for patient s rights and see this appointment as a way of furthering my
ability to serve those with disabilities
19 What do you see as the objectives and goals of the body to which you s&ik appointment
The Disability Advisory Committee helps identify and address the issues
that impact the residents of this city who have disabilities Once the
issues have been identified the goals of the committee are to discuss
possible solutions and bring them to the attention of the City Council
20 How would ) ou it eommead the objectrves and goals of the body be changed or auonented?
I would like to see more direct contact with the city engineers traffic
division police department, and possibly the city attorney s office to
address specific issues affecting those with disabilities
21 How would you help achieve the body s cstablislied objeatvLs and goals"?
PKIN ILL, UN /*CYCLED PAPER
et51plattlie
Page 4 of Application
I have been a very active and concerned member of this committee having
attended every meeting and event for the past 5 years I helped establish
the "Kids Carnival" for children with disabilities 4 years ago, and have
been one of the major organizers of that event
22 V, hat special qualities can )ou biing to the body LO which you seek appointment')
I believe that my background and training in healthcare and law allow me
a very unique perspective with regard to representing the interests of the
disabled citizens of Culver City
REMINDER All information on Om application will become a public item d and be available for
public inspection or duplication aq autbomed by law
I hereby certif3 that the foregoing information IS torrect to the best ol my knowledge
You mi. ins it,,c1 to attach additional pages, enclose a copy of your resume oi submit supplemental
inform loon which you feel may assist the City Council in its evaluation of your application
Submit application(s) and attachments to
City of Culvia City
Attention City Clerk
9770 Culver BouleAard
Culvei City CA 90232-0507
(310) 253 5851
OPTIONAL
In order to assist clic City Council in suiting to balancL appointments in tat msof geogiaphic !ovation of
residence and/oi business dhnicii) g ridcr and age the tam ., mg information is desirable but not
1 equti ed for application submission or dppointrnent
If a City resident for hov, long' It a C ity business ovn neriopeiator foi how long)
Year of Birth Male Felrialt. FLIMILIty Si tri ihe
PRINTRD Ng RECYCLED PAPEFIDr Jay J She
066 Phone
Email
tOMINNOMIN1
Professional Experience
I have successfully merged my 20 years of medical and chiropractic education and
practice with my legal training in the fields of health law and worker's compensation As
a volunteer attorney at Bet Tzedek I specialized in cases dealing with Social Security
Disability before the California Department of Health Services and Petitions for
Conservatorship of disabled adults At Heisler & Bray, my practice consists of
representation of employers in defense of Worker's Compensation cases With my
background, I have become the firm's specialist in medical lien negotiations
Employment
HEISLER & BRAY, Woodland Hills, CA, Associate Attorney
December 2002 - Present
BET TZEDEK LEGAL SERVICES, Los Angeles, CA, Volunteer Attorney
August 2001 - December 2002
MEDIA DISTRICT CHIROPRACTIC, Culver City, CA, Clinic Director
June 1986- Present
LOS ANGELES COLLEGE OF CHIROPRACTIC, Whittier, CA, Clinical Instructor
January 1984- May 1986
BETH ISRAEL MEDICAL CENTER, New York, N Y, Resident Physician
1982-1984
Education
LOYOLA LAW SCHOOL, LOS ANGELES, CA
Juris Doctor, May 1999
Recipient of Bancroft-Whitney Am Jur Award in Marital Property
LOS ANGELES COLLEGE OF CHIROPRACTIC, VVHITTER, CA
Doctor of Chiropractic, 1986, Summa Cum Laude
CETEC UNIVERSITY MEDICAL SCHOOL, DOMINICAN REPUBLIC
Doctor of Medicine, 1982
SCHOOL OF MEDICINE, UNIVERSITY OF ROME, ROME ITALY
UPSALA COLLEGE, EAST ORANGE, NEW JERSEY
Bachelor of Science in Biology, May 1977, Summa Cum LaudeLICENSES / CERTIFICATIONS
The State Bar of California, Bar # 213617 June 2001
Recipient of the Wiley W Manuel Award for Pro Bono Legal Services June 23, 2003
Qualified Medical Evaluator, State of California, Division of Worker's Compensation, 1991
Industrial Disability Examiner certification by the California Chiropractic Foundation, 1991
California Chiropractic License # 17818, Board of Chiropractic Examiners, 1986
National Board of Chiropractic Examiners, 1985
Educational Commission for Foreign Medical Graduates, 1982
Professional Associations
American Bar Association, Health Law Section, 1996- present
Los Angeles County Bar Association
Culver-Marina Bar Association
American Chiropractic Association, 1986- present
California Chiropractic Association, 1986- present
Board of Directors 1990-1996
Los Angeles County Chiropractic Society
Board of Directors 1988-1993
Doctor of the Year Award, 1991
San Fernando Valley Chiropractic Society
Director 1990-1996
President 1988-1990
Exchange Club of Culver City, 1992-present
President 2004-2005
Disability Advisory Committee, City of Culver City
Chairman 2004-2006
References Available upon request
/1.CITY OF CULVER CITY
R:ECENED
U770 CULVER BOULEVARD P 0 BOX 507 CULVER CITY CA 90232
1206`
MAY 17 PM 14- 57
APPLICATION AND BIOGRAPHICAL DA CIPACOIFTY
FOR COMMISSION, BOARD OR ADVISORY COMMITTEE
CCULLEVREIcR
MEMBERSHIP
(please typo or print)
The into' illation contained on this form is for the use of the Clot Council in order to rift vdcanc9...6 09
City C ommissions Boards Advisoiv nmrninces Lack I nices However all mfoimanori on this
form will bet ome j piihlit rt.( tiril and be available tok imbue inspcetion Or duplication as
atithormd bv law
Separate applications must be submitted for each body to which applic.ttion is being made
Guile' al Infot mama
I Identify the Commission. Advisoiy Commiliu. or Task Row to which appointment is desirLd
0-u.lvar 0%6664 141 _AcPvt r Co PA mitt—e—e.
If applying for a position on the 1,mdlordillnant Medial ion Board, indicate whethei >Oil ale
appbn me, as a tenant representathe ) landlord n-pri-sultail C., ( ) at member at-large
representati‘e )
Call thi. FioLstng DA tston it 1310) 253 5780 a you I, lye in queotem regaiding ettRitylltn for Ldndlo-clautu itMotlidtmu
Bo.rd posittonh
3 Name e-R061n —reAen56.\-3 Tt. 11111111111111111.
AddrLss
=111P
—
7ip 'S O 2:56
Business 4
Ttk.phont. .10.101111111.111._
Address Zip 900 l(S.
F riiiil addrx,ss 4niie .1^ f lre oii o (1R Ellitiet )(mai sItt 4,1 if 4 Communit y Service
(Lia.1 hoards commissions tommittees and organizations on x, filch you have serted or eurrGnilv
6M ye, OffICGS had and iii v.lrit L11) )
!Lex et +LA 4AVISor-1 C45,Lee|10 10|cecz
Culver C ity Empire/ 6)es rake pntdo n offectevolY Proodeng ele higfm.544evei car $Oft JCA 2 10 ennch rho qtaihty of life for the co r n .ntio, y by &P rong on our
me' cvt lore Man severer) nvo years of p1.14)1ro set-Vs° by au present commitment aryl rfratir.dfron to meet lbe GlIebenges o f 1130 ft tov
111 .4.171C1 Fltr "nun IPage 2 of Application
5 Employment
(Title and duties current and past )
&mor n
VCCdtptialT Qe-6,61.t.
12, 4toia dunseTor
IRO — presa:E.
• deAalop-rehtLicaLfitiunc, pro tkanus rfoi- (4.3144%. 4646114LS
• 5°Pu:44w' 44.0.4tm
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Personal
7 Aie you a Li S citizen )' ties YES NO 8 Are you registered to vote in CuIvei City? I NO 9 Have you e% er been convicted fined impusoned, oi placed on YFS NO probation for a felony oi foi a misdemeanor imolving fraud?
If) Ha. you ele, worked tor the City of Culver City ? (If yes, list dates and YES NO V
names of &pal tments )
11 Aryuu ILItt RA to any tAll I Gilt City employees or appointees of the City YES NO V
of eliker Coy? (If indicate name and lelationship )
12 kre you aware that financial distlosuie may rupmcd
YES NO (e g sources of income, loans and sifts investments intLicsis in Ica]
property )
13 Rules or law and ethics prohibit inembizs from paiticipalltig in and YES NO voting on matters in which they ma v havt. a dirw i.i indirect financial
interest Art. you aware of any potential conflicts of interest which may
de%elop from your occupation or financial holdings in raation to voui
responsibilims as a membei of the bod y to which you seek appoiniment?
(It 'yes please indicate any potential conflicts )
14 1-I ken oi ale theie now any business cireuinstain_L,s which YFS NO V
6 Education
(Include profession il orvocatu-inat licenses and certificates )
PRINTED ON FitLYLIct) l'APEP
/3
•Page 3 of Application
mi g ht 11. fk.c I iciwt rst,b on (tit propritty of Nour so-% I rig 44 J ricrnhcr
ol any body to which you might be ippoinit19
15 Hov, man y mu ting, of tlik. Commisvon nodal or Con-mutt. to which you are interested in being
appointed have .oii attended in the last year' /5 1(3 How much timt on cl monthly basis do s no inhtipatc. spi.nding on imparition foi and attendante at
meetinsfs of the body to v hich von desire appointment'1
le kit
Ini41
17 Why are you interested in appointment to a CH} Commission Boat d Committee or Task Force'
Sr kaue bee-en olt
,,t1tvi ditekithult
e4n14•'/K41.61-4-• i01-- leda.44-•
ak7 e4-4-.2... ..) Juiu_e o ,la4.0.4,, cdc44 ,,t,
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C1444 01-64-1 i 14)-44eft %onith 03 at entortea r11-0-inaig-4--p-) crtha-x-d -td 4
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18 \\ Ii it is thut spttificallv in your hacigiound training education or interests ich qualifies you se4,4014V-
••n•• I." I 6stice...„
an appointu 9
"X" ItaLe. been. ,e,,,,Ato-a/eak as c4 (Ret.titiott L4to rt_, Cot.trirholor • 40 AD tars
"X+. Vlag beery' ral It.41 rya e, Ca
veer to Istast si pee,ote, ',No, atwoa
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= 'have. ed.840.4ed ers &J. Corm-A 44st g tx1 DrSCIA I 2411,41-01t4. dc ru --
CA.Cr
-brArA0C/A1 pets u4t alSq. tts, a AA Assivieze 441tell--(4.41A ceLes on
0 Istimn I1.1.% Com
19 What do you see as the o ject 'es and pa g of the body to Ala you scLic appointment 0
-the, c c iz:. A c. 4.4.,e,k-Lay, is
40 be. CertRtel. 4014t resicteet-4i. oc- ow,-
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20 How v. ould ) on n commend fin. objcctiscs and goals ot the body be Ghan,p-ci or
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21 How vcould you help achieve the body s established obiLi_tivLs and goals'
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Page 4 of Application
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22 What special qualities can you bring to the bod y to which you seek appointment?)
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REMINDER All informa ion on Um application vull become a public recant and be available lot
public inspection or dor& awn as Ruthann(' by raw
Liman certify that the foregoing information is 4.orrect to the best ol my knowledge
You all, ited to attach additional pages enclose a copy of your risumi, ()I ubiiut suppILmental
infirm if ion whiLh you feel may assist the City Council in its evaluation of your application
Submit appliLation(s) and attaLlunents to City of CUIS1.1
Attention City Clerk
9770 Culver Boulevard
Cul%L1 City CA 90232-0507
(310) 253-5851
On ION
In order to assist I& City CouniAl in KLLing to balancL appointments in tei nis of geogiaphic loation
iesidence andioi businos Gaina.11) et.iidis and agL the follov, mg information is desuable but not
iequued for applicdtion submission or appolin [tient
If a City iesicknt for hove long 9 .26 161 s It a C ity husioes., ovener/opeiatoi foi how long9 AJO
Year of Birth Male Pernik. X FElliIILILy 5/1)8
PANIFT Ott qE^YCLED PAPER
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