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• a J City of Mounds View
<br /> 2401 Highway 10
<br /> `� Mounds View, MN 55112
<br /> o4'"Pss'Partnc+'S�'‘Q� Phone 763-717-4000 Fax 763-717-4019
<br /> www.ci.mounds-view.mn.us
<br /> Application for Advisory Boards and Commissions
<br /> Board/Commission Applied for: c&--ilow Derelof,,, (o n,,;ss2C)1
<br /> Full Name (Please print): �cciitccvi i--J- /4..c-i-k-e
<br /> Home Phone: .7 3. Zc Kr- '2 Work Phone: 's7, VG,'6, - 5-29c.64,
<br /> Cell Phone: ' -(a3 - 7O2 - lo3lp Years lived in Mounds View: "3- s—
<br /> Address: 290 17 date-- / /(ouJ Ce,v ---
<br /> Email address: na ,CG4akup16vt -/mow-�� -
<br /> Qualifications you want to have the Mayor and City Council Consider:
<br /> • Skills and Interests: 7.c--es c t / Z /b,fre /,-y c, )1 tds6epd ted d,-, _ /1-/ty-.7 -(7-7
<br /> 044cl- - L'1/-C- 56g.�.d;K, 74-7Vlecis;dam 6r,‘-,- *4"7s lel rx=e-ie s - Gt6e
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<br /> Cp 01)fl a vl% ! 4 --i otic r/ a-4 L 3,"3:S Cc.-4-7c( SO AJ-722,5 s 4jl��'J ere.,s s _
<br /> Employment, Occupation or other Experience: �C� a ✓`�, (5,,,-,c-_,,- d 71 .ski-re-l(
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<br /> Memberships, Accomplishments or Other Qualifications: _7' r .5,2_,- ,r ��
<br /> `1//c°1,4,14cts Vice u `s (,;',,11.4/Do It-c_44 s;-1...-e cEi.c 62tusr-t%ge-E- _" Ac<,,--' S.-e,.
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<br /> Ger tr. (.-1 ,'.2,-,.5 574` s -
<br /> Please state� your reason for wanting to serve with this group: 71/(y .mot, ,-s 11/6-1-,CIS
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<br /> Signature: irAtrA. Date: (7/.. /o0
<br /> • (Your response to any of the above inqui les may be continued on the back of this form and you may attach any
<br /> other material that you would want the Mayor and City Council to consider.)
<br /> The City of Mounds View is committed to the policy that all persons shall have access to its programs, facilities and employment
<br /> without regard for race, creed, color, sex, age, national origin or handicap.
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