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F <br />� r <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)appliedfor: AV lrlCi4nlbi C_O/VA?ISSIOK <br />Full Name (Please Print): <br />vul hone: 7L 79'1 7336v <br />Address: Z0 `I 7 f� 7�/# h <br />Years at this address:. d- I <br />e MS 0 to <br />Work(Cell Phone: 3 �6 o 3 8 -s <br />(/-e. <br />Years you have lived in Mounds View: 350 <br />E-mail Address: <br />Experience and Qualifications <br />Skills and Interests: <br />Employment, Occupation or Other Relevant Experience: <br />/'-h'klej <br />Memberships, Accomplishments or Other Qualifications: <br />Ae_ r"�"t-/ oD% Iq///-/�I-S CA, - <br />Please stateyour <br />/reason for wanting to serve with this group: <br />Signature: � � Date: 1:>1 3 / 2 c)/ y <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 at/ persons shall have access to its programs, <br />facilities and employment withoutregard for race, ethnicity, sex, age orphysical abilities. <br />k'151 -14P01:01 R(ND <br />