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MOUNU►S VIEW 2401 Mounds View Boulevard " Mounds View MN 55112-1499 (763) 717-4000 * Fax (763) 717-4019 infota'�.moundsviewmn.org i www.moundsviewmn.orp FIOMWA � To be completed by Mounds Vi Date Application Received: (T - ❑ NEW APPLICATION (never served) RENEWAL APPLICATION ❑ APPROVED Date Term Expires: I APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION Na Phone}�/ � br1' i Stat / Zip �'/J Phgt ( 2— 2-7 /� Years a9thi ddress: N Yeajs&qct have lived Ciinn'Mounds View: tAj5PIhfi)" COMC/45f Fyt)2.1— ❑ Economic Development Commission( Tanning Commission (Meets the 11 and 3'd (Meets 31 Friday of each month at 7:30 a.m.) wednesday of each months at 7:00 p.m.) ❑ Parks, Recreation & Forestry Commission ❑ Police Advisory Board (Meets the 4"' Thursday of each month at 6:30 p.m.) (meets on an "as needed" basis) ❑ Comprehensive Plan Taskforce ❑ Other ills and I t0 (Employment, Occupation or Other Relevant Exoerience: (Memberships, Accomplishments or Other Qualifications: J What is your main reaso t for wanting to serve on this Commission/ComrrAttee: 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, if selected, notifying your of your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is ;Idered public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, government service, veteran status. On n individug4� appointed, the following additional items of data are considered public: residential address, )hone number, email address. I haver and under a the Tennessean Warning and certify that the statements in this application are true and Applicant Signature: _ Date: Your response to any of thea ove inquiries 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.