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10/30/2009 FRI 8:43 FAX 952 920 0982 Lang Nelson Assoc. Inc. 0002/005 <br /> • <br /> MOUNDSlittIRAT <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:ituorli tompiiii)eulturolc, )).f,taleporaii- eartivii5S1tY1 <br /> Full Name (Please Print): 141lj 5114‘141/1 <br /> Work Phone: I G2.-10--/-4114-I Work/Cell Phone: 1113-1W-6/53 <br /> Address: 17bb 511wir Leal. 2D1 Vrei,o PI, 112-- <br /> Years at this address: 2- lyr Years you have lived in Mounds View: <br /> E-mail Address: hbliy c*v (441 44Gbtra,i I.elm • <br /> Experience and Qualifications <br /> Skills and Interests: <br /> 3c 61-4-1-ete1nitsi <br /> Employment, Occupation or Other Relevant Experience: i• <br /> 5e,e, 0,-1-tathee1 <br /> Set, a+1094_ci -Ockes5'idAP-1 r.051)4Nd <br /> Memberships, Accomplishments or Other Qualifications: <br /> 5f,e- c -4- thd <br /> Please state your reason for wanting to serve with this group: <br /> 52,t 0,44rte,hed <br /> • • <br /> Signature: 11LicAILJ Date: 16/2-111 <br /> (Your response to any of e 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 /> . .„. <br />