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MOUNDS ,VIEW <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) applied for: P2 fir` °i 14 <br />Full Name (Please Print): tiA -� L Ff Ry Lo '-f ° N <br />Work Phone: 76 3 - `ir S 6 -- 3 t 1 / Work/Cell Phone: <br />Address: S'26o Lang %�1 <br />76� -`f,'6 -Z0I <br />Years at this address: 6 I e ,, rJ' Years you have lived in Mounds View:3�e�<-r <br />E-mail Address: 1e16,1e)o.Pson ) ygkas <br />COP -1 <br />Experience and Qualifications <br />Skills and Interests: <br />Employment, Occupation or Other Relevant Experience: <br />V, i 1-e � I 10,-TeJ` 1%_P' \,L e -- OJY Cc�rvi'e� <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for wanting to serve with this group: <br />��As1 I TO gR+ 1v^va( �j in -Fh:3 Com. r /n14 -y <br />Signature:/G— 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 or physical abilities. <br />