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k <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: x,45, <br />Full Name (Please Print): Ci niD <br />Work Phone: )1��- o,'S 3 %(4 <br />Address: 616 <br />Years at this address: <br />E-mail Address: <br />icz�/rte r� <br />Phone: <br />/r A) <br />Years you have lived in Mounds View: <br />Experience and Qualifications <br />Skills and Interests: <br />� <br />badIll <br />�y Employments, �Occupation or Other Relevant Experience: <br />Members ips, { omplishments or Other Qualifications: <br />Plase state y ' r feason' for want ni g to serve with this group: <br />Signature: Date: <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 />