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1flOUNDS Yli:.rY 2401 Mounds View Boulevard " Mounds View MN 55112-1499 (763) 717-4000 ' Fax (763) 717-4019 info@ moundsviewmn.= I www.moundsviewmn.org e D G To be completed by Mounds View: Date Application Received: 0 NEW APPLICATION (never served) ❑ RENEWAL APPLICATION ❑ APPROVED Date Term Expires: APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION rvarrt6 ` Addre,7� Phone #13_ 76' �5 C /S eJ State Zip: Ph #2:z Years at -Pis address: Years you have in Mounds View: Emai �t a k)�t C c �5T Economic Development Commission (Meets 3`d Friday of each month at 7:30 a.m.) ❑ Parks, Recreation & Forestry Commission (Meets the 41 Thursday of each month at 6:00 p.m.) ❑ Comprehensive Plan Taskforce Skills and Interests: ❑ Planning Commission (Meets the 11' and 31d Wednesday of each months at 7:00 p.m.) ❑ Police Advisory Board (meets on an "as needed" basis) ❑ Other _ Ph /i E � Lr s»I t, y -Cit.. P 0 Ly -15 -- _4. 1t.l`- 4 9R1 cf rt-. d Yom - 0 /i' qj C G• r K F sic Employment, Occupation or Other Relevant Ex erience: Memberships, Accomplishments or Other Qualifications: What is{your main reason for wanting to serve on this Comm ission/Committee: iz t --t- ,{ { { 11 NESSEN WARNING: The information provided by you on this application will be used to determine your suitability for appointment to an advisory mission.. Participation as an advisory commission member is strictly voluntary and you are not required by law to provide this information. However, ild you not furnish this information the City may have difficulty determining your suitability for appointment, contacting you regarding your information, it selected, notifying your of your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is ridered public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, government service, veteran status. Once an individual is ap inted, the following additional items of data are considered public: residential address, )hone number, email address. l have r understandennessean Warning and certify that the statements in this application are true and Applicant Signatu / /' f Date: -3 b /v� � , f C), Your response to any of the abovei`nquiries may be continued on the back of this form and you may attach other information that you would like the City Council to consider. 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, ethnicity, gender, age or physical abilities.