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City of Mounds View <br />24m1 county Highway '10 <br />Mounds View, Nllq 551'12 <br />763-7'17-4000 <br />G7�5iBX89 o@r1f�s-,Ia'd-amrilLi:C':��a <br />A plio�� gn Jor-AOVLIS rtL of _ — <br />Group(s) applied for: <br />�r <br />5S/ <br />Full Name (Please Print): <br />Worl< Phone: Work/Cell Phone: _76 <br />Address: _(- <br />Years <br />Years at this address: i =, Years you have liver,) in Mounds View: 1 ` <br />t <br />E-mail Address: <br />-Experience nc1_ <br />a0 alifica£iotm- <br />Skiillyls and Interests: <br />Employment, Occupation or Other Relevant Experience: <br />cJ A C <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for wanting to serve with this group: <br />l <br />_- <br />'> <br />Date: <br />(Your response to airy of the, nbovo inquiries play bo continued ort ll1a back of this form and you <br />ms�'y attach other information thatt you would lilt" (lto City Council to consider.) <br />The City of Mm.uids NOW is eonvnitted to the policy that all poisons shall have access to its programs, <br />facilities and employment withoutrega/ti fenace, ethnicity, sex, age orphysicol abilities. <br />