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City of Mounds View <br />2401 County Highway 10 <br />Mounds View, MN 55112 <br />763-717-4000 <br />Group(s) applied for: L-)-' <br />Full Name (Please Print): �r mm M L � I� <br />WorkPhone: <br />Address: a3L 3 <br />Work/Cell Phone: <br />^r_ <br />51 <br />Years at this address: Years you have lived in Mounds View: c9 q <br />E-mail Address: i tom, L24L ( coYnraST Ila E <br />Experience and Qualifications <br />Skills and Interests:{ ISA/f Ij ✓ /U©� _ Prp t l ©r9 J <br />V01 Qn 4e"er, work . <br />Em to nt, Occupation or Other Relevant Experience: <br />'e�pe_ emp icned C'VMrGi1-v pro 5ira ng MJku <br />S$ 5�elh cty��ticAS/SJ G�a"%��SC' 2S<5h <br />Memberships, Accomplishments or Other Qualifications: <br />!Non) —�rc9�tt V C7 � u t)4 -et' C <br />GII(APjer COMM is' le) AJ <br />Please state your reason for wanting to serve with this group: <br />(i'orr� IhU"e 0-6 Cokorl,t-C-22 <br />Signature: ,-::-)��� Date: /� 4Q0 <br />(Your response any of the above inquiries maybe 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 />