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4 z <br /> MO 11 S IVIEW <br /> City of Mounds View <br /> 2401 County Highway 10 <br /> Mounds View, MN 55112 <br /> 763-717-4000 <br /> Application for Advisory Commissions and Committees <br /> Group(s) applied for: F', D , C_ . <br /> Full Name (Please Print): 1 .s�Cxel L. SA- l J e ns on <br /> Work Phone:' (, 3-1 1-5(--( - 13 i3(cWork/Cell Phone: (Dia - 39co 0 3 S <br /> Address: r( n1 C() A-tiQ _) /1V\ (kid1 c)6 V t c->-u3, .ANikk J-7-5. 113 <br /> Years at this address: '�t Years you have lived in Mounds View: ??5 <br /> E-mail Address: -) k r) c2“_-_,.f ' @ c"? h G ci c,C f 37 <br /> k.) <br /> Experience and Qualifications <br /> Skills and Interests: I rl _ h O ryl C� - c_k o s bus in �' <br /> Employment, Occupation or Other Relevant Experience: j LtS i n c5 B-CA 0A(r)i rscr,-7 co <br /> y l i <br /> C� c'c� i^�,t-. i �q � �..�-�u'S i�� 1'Y�c�ft Cc o�.r�vLt� �� ���.�pe_o�t c, <br /> CcI Lbyh el -- �i��Ia (0\iLci i'\i s'ate:_S ,-; <br /> Memberships, Accomplishments or Other Qualifications: t.Q 'i c-'ccs S r h\.f Pc, v <br /> 1- -Rec, CUrn In ` GS t (1 , LG) .j ccs c"` !✓ t t n n t tl C (loin' <br /> n' i s'c(on t <br /> 1Y 1--t0l S CAub 'ai'1a me \( COMA- i - d.`k ` c'K ` br C;i s <br /> Please state your reason for wanting to serve with this group; r socct(c�; Il <br /> 8. c. /IA oU-1iC L) LC J P 0--)S Pe�. <br /> Signature: ....'j _ Date: 1 2/ 6 /2-U t:� <br /> (Your response to any of the above inquiries may be continued on the back of this form and you <br /> may attach other information that you would like the City Council to consider.) <br /> The City of Mounds View is committed to the policy that all persons shall have access to its programs, <br /> facilities and employment without regard for race,ethnicity,sex, age or physical abilities. <br />