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MOUNDS VIEW <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: ,Fe o ,l o nn i C Lha/ 12'W/v(OnM en? ( ,fl i. <br /> Full Name (Please Print): an%r/ J&S� Lac o,i <br /> Work Phone: 763- 780.88 cc) Work/Cell Phone: 610 597--7379 <br /> Address: BO V6 Lbodlaw. <br /> Years at this address: /`( Years you have lived in'Mounds View: a/ <br /> E-mail Address: DJC Q en vir on lob. COM <br /> Experience and Qualifications <br /> • Skills and Interests: <br /> Ou t or vods • <br /> Employment, Occupation or Other Relevant Experience: <br /> Memberships, Accomplishments or Other Qualifications: <br /> CDC /as-l� 3 year rs <br /> 11 -01 -10 A 0 9 2 7 I fJ <br /> Please state your reason for wanting to serve with this group: <br /> - <br /> Woo IC/ li ke 5' see So,e v`f Thr Et e <br /> gals -it-/o(14 <br /> Signature: J_-'- Date: /Oq/-/O <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 />