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MoUNms"1ViEy <br />2401 Mounds View Boulevard * Mounds View MN 55112-1499 <br />(763) 717-4000 ' Fax (763) 717-4019 <br />barb. benesch@ci mounds -view mn us_ <br />www.ci-mounds--view.mn.us <br />To be completed by Mounds View: <br />Date Application Received: <br />❑ NEW APPLICATION (never served) <br />❑ RENEWAL APPLICATION <br />❑ APPROVED Date <br />Term Expires: <br />APPLICATION R Pu ABUOSO0 OOAO10,1011 MMITTEEMOMMISSION <br />ame: I./ <br />U <br />Address - <br />c93535 {- A I� Phone #1: <br />l`�'t-t A-V r- �S�' s_�• l� �cS'_/ <br />City: N ul/ State: M� Zi 5'S"1 1 Z <br />V, S p= Phone #2 <br />Years at this address: Years you have lived in Mounds View: <br />U <br />/O <br />Email: J trGsfi71. (il� vUm <br />• • Midi �•• o • <br />❑ Economic Development Commission �C Planning <br />Commission (meets the 1=' and 3rd <br />(meets 3"' Friday of each month at 7:30 am) <br />❑ Parks, Recreation & Forestry Wednesday of each months at 7:00 pm) <br />❑ Police Civil Service Commission <br />Commission (meets the 41' Thursday of each "as <br />month) (meets on an needed" basis) <br />Skills and Interests: j <br />Em to or Other Relevant Ex erience: <br />Ft,,�ccu�tion <br />{k-,t� ' . !ten f�2,.Q9�� e- ''!- , �.C�c •�io�.. % � :,.—cx4-... <br />Memberships, Accomplishment or Other Qualifications: R. <br />IOLA,2r C <br />What is yoyr main reason for wanting to serve on this Commission/Committee: <br />Z cam,, < <br />k <br />r <br />TENNESSEN WARNING: The information provided by you on this application will be used to determine your suitability for appointment to an advisory <br />commission. Participation as an advisory commission member is strictly voluntary and are by <br />you not required law to provide this information. However, <br />should you not furnish this information the City may have difficulty determining your suitability for appointment, contacting you regarding your information, <br />and if selected, with your duties on the advisory commission. Under Minnesota State Statute 13.601, <br />subd.3, the following Information is considered <br />public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, prior <br />government service, veteran status. Once an individual is appointed, the following additional, items data <br />of are considered public: residential address, <br />telephone number, email address, I have re a d understa the Tennessean Warning and certify that the statements in this application are true and <br />correct to the best of my knowled e: , <br />Applicant Signatur <br />Date: <br />Your response to an of the quiries may be continued on the back of this form and you ay attach other information <br />that you would like t y Cou cil 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 without regard for race, <br />ethnicity, gender, age or physical abilities. <br />