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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: C7 C.- a 6-� 60 I-kq kh lis I 0 1--1 <br />Full Name (Please Print): 0 -&—kj, , 'S' Z- k" I C-1 '_7 <br />Work Phone: / 2- �' �� 2 �.3 Work/Cell Phone: <br />Address: �L % 7 s TZ-- V ( -C r (" <br />Years at this address: 2 '_� Years you have lived in Mounds View: <br />E-mail Address: <br />Experience and Qualifications <br />Skills and Interests: <br />Employment, Occupation or Other Relevant Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for wanting to serve with this group://i /4 <br />11 <br />Signature: Z'�-ep- � 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 />