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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: > QC \) 1t\tk � 2 -ed �taw(� I Jg� cA oc lS <br />Full Name (Please Print): leicwl- <br />Work Phone: U awl 53clI I Work/Cell Phone: Borne <br />Address: �j3�0 ala cc�� Qne'A <br />Years at this address: Years you have lived in Mounds View: $ <br />E-mail Address: My-otwti Q W60a • Coles - <br />13���- <br />Experience and Qualifications to H�ctrS.. <br />Skills and Interests: <br />Employment, Occupation or Other Relevant Experience: S-ce- A44A6KK-4'14 <br />Memberships, Accomplishments or Other Qualifications: se . P -14 i <br />Please state your reason for wanting to serve with this group: <br />Iles is tyu-�- 60"'t- NL'W a -d -}o V\"V, o-� to W4."- CVtVj0+9X- <br />Signature: � � ___.... pate: a a 17 <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, ethntrlty, sex, age or physical abilities. <br />i`..-13-'I1ia^'I:O; R C V 0 <br />