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<br /> <br /> <br />2401 Mounds View Boulevard * Mounds View MN 55112-1499 <br />(763) 717-4000 * Fax (763) 717-4019 <br />barb.benesch@ci.mounds-view.mn.us <br /> www.ci.mounds-view.mn.us <br /> <br />Applicant Information <br />Name: <br />Address: Phone #1: <br />City: State: Zip: Phone #2 <br />Years at this address: Years you have lived in Mounds View: <br />Email: <br />Commission/Committee Applying For (If applying for more than one, please rank in order your desire to serve). <br />X Economic Development Commission <br />(meets 3rd Friday of each month at 7:30 am) <br /> Parks, Recreation & Forestry Commission <br />(meets the 4th Thursday of each month at 6:00 pm) <br /> Planning Commission (meets the 1st and 3rd <br />Wednesday of each months at 7:00 pm) <br /> Police Civil Service Commission <br />(meets on an “as needed” basis) <br />Experience and Qualifications <br />Skills and Interests: <br /> <br /> <br /> <br />Employment, Occupation or Other Relevant Experience: <br /> <br /> <br /> <br />Memberships, Accomplishment or Other Qualifications: <br /> <br /> <br /> <br />What is your main reason for wanting to serve on this Commission/Committee: <br /> <br /> <br /> <br />TENNESSEN WARNING: The information provided by you on this application will be used to determine your suitability for appointment to an advisory <br />commission. Participation as an advisory commission member is strictly voluntary and you are not required by law to provide this information. However, <br />should you not furnish this information the City may have difficulty determining your suitability for appointment, contacting you regarding your information, <br />and if selected, with your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is considered <br />public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, prior <br />government service, veteran status. Once an individual is appointed, the following additional items of data are considered public: residential address, <br />telephone number, email address. I have read and understand the Tennessean Warning and certify that the statements in this application are true and <br />correct to the best of my knowledge: <br />Applicant Signature: Date: <br /> <br />Your response to any of the above inquiries may be continued on the back of this form and you may attach other information <br />that you would like the City Council to consider. <br /> <br />The City of Mounds View is committed to the policy that all persons shall have access to its programs, facilities and employment without regard for race, <br />ethnicity, gender, age or physical abilities. <br />To be completed by Mounds View: <br />Date Application Received: _________________ <br /> NEW APPLICATION (never served) <br /> RENEWAL APPLICATION <br /> APPROVED Date___________________ <br /> Term Expires: ______________________ <br /> <br /> <br />APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION <br /> Dennis Farmer5117 Irondale Road 612 867 8293 <br />Mounds View MN 55112 651 602 15521313dennis.farmer@gmail.com <br />Please see attached <br />Please see attached <br />Please see attached <br />Please see attached <br />11/8/2017