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City of Mounds View <br />2401 County Highway 10 <br />Mounds View, MN 55112 <br />763-717-4000 <br />Group(s) applied for: T DG <br />Full Name (Please Print): <br />AAIG*Phone: <br />Address: : a.. <br />Work/Cell Phone: <br />Years at this address: /9 Years you have lived in Mounds View: <br />E-mail Address: Aa, A Inr__ Zarc9n E co"e-12t1.1?a?I-- <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: <br />Tti;S Wo0/V & <ay A)', -a/ fielm, - woo IV like 3o see sonic o -F j-6, <br />red, LA,/op me,l¢ proJe�sLs <br />Signature: l� 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 />