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MO]NDS�VIEW 2401 Mounds View Boulevard Mounds View MN 55112-1499 (763) 717-4000 " Fax (763) 717-4019 barb, benesch(a)ci.mounds-view.mn.us www.ci,mounds--view.mn.us To be completed by Mounds View: Date Application Received: ❑ NEW APPLICATION (never served) ❑ RENEWAL APPLICATION ❑ APPROVED Date Term Expires: APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION Applicant Name: ap� ettiSa k Address:�`,�� 7 ��h�J�{�iU� I Phone ;3 79`1 City-NPuA �/! eu� Statefgyt/ Zip: Phone #2(2 396 Uf Years at this address: 720 Years you /h e lived in Mounds View: Email: Seri y'iCommission/Committee Applying For (if applying for more:than one, please rank in order your desire to serve). ❑ Economic Development CommissionPlanning Commission (meets the 15' and 31d (meets 3td Friday of each month at 7:30 am) Wednesday of each months at 7:00 pm) ❑ Parks, Recreation & Forestry ❑ Police Civil Service Commission Commission (meets the 4'h Thursday of each month) (meets on an "as needed" basis) i,Experience and Qualifications Skills and Interests: r /f W, e r•, r /4 Employment, Occu ation or Other Relevant Experience: /Pe Memberships, Accomplishment or Other Qualifications: 2-0,-P 0 i l R .n »t � &144.11(,f551er1A V 1_1�2n) G' What is your main reason for wanting to serve on this Commission/Committee: TENNESSEN WARNING: The information provided by you on this application will be used to determine your suitability for appointment to an advisory commission, Participation as an advisory commission member is strictly voluntary and you are not required by law to provide this information. However, should you not furnish this information the City may have difficulty determining your suitability for appointment, contacting you regarding your information, and if selected, with your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is considered public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, prior government service, veteran status. Once an Individual is appointed, the following additional items of data are considered public: residential address, telephone number, email address. I have read and understand the Tennessean Warning and certify that the statements in this application are true and correct to the best of my knowledge: Applicant Signature: u,�t Date: Your response to any of the above ingd(ries may be continued on the back of this form and you may attach other information that you would like the City Council to consider. The City of Mounds View is committed to the policy that all persons shall have access to its programs, facilities and employment without regard for race, ethnicity, gender, age or physical abilities. l y I! I, o I 4!