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09_3-0.11 A0 :S0 1J <br />:R91% <br />City of Mounds View <br />2401 County Highway 10 <br />Mounds View, MN 55112 <br />763-717-4000 <br />Application forAdvisory Commissions and Committees <br />Group(s) applied for: <br />Full Name (Please Pri <br />Work Phone: 763 18-Y 7336 Work/Cell Phone: .3K 413** <br />Address, <br />Years at this address:_ p <br />E-mail Address: .>Tcfl,P, (r- M a <br />Skills and Interests: <br />Years you have lived in Mounds View: ,3_'� <br />Experience and Qualifications <br />Employment, Occupation or Other Relevant Experience; <br />15aIP <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for w nting to serve with this group: <br />& O, 5e0l/c. N <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 Illew 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 phys/caf abilities. <br />f'd 8£97981£9L <br />s,uosueneaS e60:80 6f bZ deS <br />