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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): 1 t4A LM <br />Work Phone: O GE- -7+U 1 Doi Work/Cell Phone: <br />Address: -1-7b0 si l uiw U, jM lel t nds Vt UA-)1On 'ice 112 <br />Years at this address: S Years you have lived in Mounds View: �• S <br />E-mail Address: 1 lD) ���� 11/1 t t l (jVViGt f i�J✓tfl <br />Experience and Qualifications <br />Skills and Interests: I oin- j [4w P ab o- joa& t2 6 pyb�tssiwwd a--nol <br />hnnk W2 K"t, I "a j 0f'9 ao-64e, <br />Employment, Occupation or Other Relevant Experience: <br />RUJ . 0 CAV -e. + Inc. <br />Memberships, Accomplishments or Other Qualifications: <br />t'vc 1��+� logit (t�iwrYilulea- �w 3�Y5. <br />l � <br />ePlas"at.Pve"yW`nw(olus�onLPr vWan �in2�g t1t0y�er-vi e �nit�hJ�t'hT�g�roup: Fz-E vrgct-+�t ��ns, la <br />I � VAAt- �kb- chit b �nv a. -,oi bait nj 'iaWl vee <br />(a } (n as i s . G�611w� //✓1 ; %%- <br />Signature: Date: <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 orphysical abilities. <br />