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2401 Mounds View BoulevardMounds View MN 55112-1499 <br />(763) 717-4000 ` Fax (763) 717-4019 <br />info@moundsviewmn.org I www.moundsviewmn.oro <br />To be completed by Mounds View: <br />to Application Received: <br />❑ NEW APPLICATION (never served) <br />❑ RENEWAL APPLICATION <br />❑ APPROVED Date <br />Term Expires: <br />APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION <br />Name 4, X^ <br />f_ <br />AddPhone #1: <br />City, State Zip: Phone #2: <br />i, _ <br />Years at this address: Years you have lived in Mounds View: <br />O=Economic Development Commission <br />(Meets 30 Friday of each month at 7:30 a.m.) <br />❑ Parks, Recreation & Forestry Commission <br />(Meets the 4' Thursday of each month at 6:00 p.m) <br />❑ Comprehensive Plan Taskforce <br />ryment, Occupation or O <br />erships, Accomplishmer <br />is your main reason for t <br />❑ Planning Commission (Meeta me 1" ana 3rd <br />Wednesday of each months at 7:00 p.m.) <br />❑ Police Advisory Board <br />(meets on an "as needed" basis) <br />❑ Other <br />NESSEN WARNING: The information provided by you on this appliCallon will be used to determine your Suitability for appointment t0 an advisory <br />mission. Participation as an advisory commission member is strtclly voluntary and you are not required by law to provide this information. Howaver, <br />rid you not furnish this information the Gity may have ditliculty determining your suitability for appointment, contacting you regarding your information, <br />ff selected, notifying your of your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following Information is <br />�idered public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, <br />government service, veteran status. Once an individual is appointed, the following additional items of data are considered public: residential address, <br />rhone number, email address. I have readand UnderstandtiYWTennessean Warning and certify that the statements in this application are true and <br />icant <br />Date: <br />Your response to any of the above'inquiriesmay becontinued on the back of this farm and you may attach other information <br />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, facilities and employment without regard for race, <br />ethnicity, gender, age or physical abilities. <br />