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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 />5 <br />Work Phonel Work/ el, hone: <br />J � <br />Address: k33� ��C7 �e� Y I I,Gkt ✓S r )� <br />Years at this address: Years you have lived in Mounds View: <br />E-mail Address: <br />Skills and Interests: <br />Experience and Qualifications <br />Employment, Occupation or Other Relevant Experience: <br />Memberships, Accomplishments or OtherQualifications: <br />In v d ��,d �c'w�i�� Z C ov � GZvwc�, j <br />Please state your reason for wanting to serve with this group: <br />V'�K�"�`�O �-e%E r/✓1/'A-1'v�-`�-7t1 ,Q.o'-vbwu_� � � �u-c,��' �—' <br />Signature: <br />Date: <br />(Your response to ahy 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 ferrate, ethnicity, sex, age or physical abilities. <br />