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UV M <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: <br />• <br />Full Name (Please Print):, <br />Work Phone: Work/Cell Phone: <br />Address: r ! R2y1wqA Vzehl,t 1 <br />Years at this address: Years you have lived in Mounds View: <br />E-mail Address: Vii 117,�t° <br />Experience and Qualifications <br />Skills and Interests: °"' 45- � <br />® 1 re, r y .3 <br />Employment, Occupation or Other Relevant Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />p ` <br />Please state your reason for wanting to serve with this group: <br />n1 iye <br />ZI/ <br />A) IhAe <br />t iat art, <br />ve' 8 <br />j <br />Signature f ,l ate <br />(Your response to any of the abo a inqcries 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 />