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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: re o n o m i c fi-,�/ JOCUC 10,0M Pn l ()oItM- <br />Full Name (Please Print): JdSeg% Laeson <br />Work Phone: 763. 780.88f0 Work/Cell Phone: <br />Address: Wt "od /a WA a <br />UP 5-97-7378 <br />Years at this address: /`( Years you have lived in Mounds View: 02/ <br />E-mail Address: DJC tO- eau;POAW a Comer <br />Experience and Qualifications <br />Skills and Interests: <br />OU` C10or Vods <br />Employment, Occupation or Other. Relevant Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />SDC las-I` 3 rhe of 5 <br />Please state your reason /for wanting to serve with this group: <br />QoJI (i II ke V0 SPP SOAP of ''bC C -11G <br />Signature: a�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 />