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-11 AO1=19 IN <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: /:�^/OfJ�C' <br />Full Name (Please Print): �.�Y'7�f✓/��� ;.� LsS <br />141ar♦ePhone.��la��755'�"�'ld`.��' Wo ell Phon : 7Cp �--�'�� 'kgs �f' <br />Address: _75-<&Pe� ezt� <br />Years at this addressL--Z?G3 %z Years you have lived in Mounds View&_%., <br />E-mail Address: /? 7 <`�— �' �,' t S X20� <br />Experience and Qualifications <br />Skills and Interests: <br />Employment, Occupation or Other Relevant Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for wanting to serve with this group: <br />Signature;?_ X12 Date: <br />v <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 shell have access to its programs, <br />facilities and employment without regard forrace, ethnicity, sex, age orphysical abilities. <br />