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City of Mounds View OCT 14 2rir,r1 <br /> • • 2401 Highway 10 <br /> Mounds View, MN 55112 <br /> Phone 763-717-4000 Fax 763-717-4019 <br /> www.ci.mounds-view.mn.us <br /> Application for Advisory Boards and Commissions <br /> Board/Commission Applied for: <br /> Full Name (Please print): ,2,>=9/Z-,-/ - <br /> Home Phone: 74,,?—7 Work Phone: La, <br /> Cell Phone: Years lived in Mounds View: <br /> Address: 7 '2 &7 c ) ... <br /> Email address: t</YVY) <br /> Qualifications you want to have the Mayor and City Council Consider: <br /> Skills and Interests: 5.". .>2-9 7 :7/9 <br /> Employment, Occupation or other Experience: <br /> Memberships, Accomplishments or Other Qualifications: <br /> Please state your reason for wanting to serve with this group: <br /> Signature: — - Date: /i-/-2/;( 2 ) 9 <br /> 4110 (Your response to any of the above inquiries may be continued on the back of this form and you may attach any <br /> • other material that you would want the Mayor and City Council to consider.) <br /> The City of Mounds View is committed to the policy that all persons shall have access to its programs,facilities and employment <br /> without regard for race, creed,color,sex,age,national origin or handicap. <br />