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std All <br />, <br />MOM ll! M , Y.,1_L Y_,9 <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: <br />Full Name (Please Pr <br />Work Phone:�Z � Work/Cell Phone: <br />Address;- K5K- f Z c W <br />a /lx-� Years 3 <br />Years at this address: you have lived in Mounds View: �O <br />E-mail Address: (oF}2�j e G , H - <br />Experience and Qualifications <br />Skills and Interests: <br />Employment, Occupation or Other Relevant Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for wanting to serve with this group: <br />Date: C -ejlo <br />(Your lesponse 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 parsons shall have access to its programs, <br />facilities and employment without regard for race, ethnicity, sex, age or physical abilities. <br />