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/0 <br /> CITY OF MOUNDS VIEW , <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW,MN 55112 <br /> 612-717-4000 <br /> • APPLICATION FOR ADVISORY GROUPS <br /> Group Applied For: <br /> Second Choice(if any): <br /> Full Name(print or type): L <br /> 1 i LL,a_„Z /lid Lk v� iYl r� <br /> Home Phone: Work or Other: <br /> 7g4_ - c503 <br /> Address: <br /> /994" ( n-werd iz � <br /> Years at this address: y <br /> Years you have lived in Mounds View: vel <br /> QUALIFICATIONS YOU WANT TO HAVE THE COUNCIL CONSIDER <br /> • <br /> Skills and Interests: e t ke.001 <br /> Employment, Occupation,or Other Experience: C0 Tt 1 Q 461 c l a,l3• �,` `. <br /> Memberships,Accomplishments,or Other Qualifications: cat a d ,b4-e' <br /> Please state your reason for wanting to serve on this committee: k <br /> Your response to any of the above inquires may be continued on the back and you may attach any other <br /> material which ou want the City Council to consider. <br /> • Signature: 74a- r 41-/; 4-tiir'-w-/ <br /> Date: % �/g� <br /> The City ofMounds View is committed to the policy that all persons shall have access to its programs, <br /> facilities, and employment without regard to race, creed color,sex, age, national orgin, or handicap. <br />