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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: <br />Full Name (Please Print): <br />Work Phone: w 5 - S 5>7 -7Y 9 <br />Work/Cell Phone: �301"e <br />Address: P5S'Y eS <hlZ�- ,i/CDce vats Ui'Et-j <br />Years at this address: O Years you have lived in Mounds View: <br />E-mail Address: b4i/Icle✓ra) <br />t � <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 />Signare: �L/ " "✓ `— Date: d-7 <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 shall have access to its programs, <br />facilities and employment without regard for race, ethnicity, sex, age or physical abilities. <br />