11-16-2017 Agenda and Packet - Laserfiche WebLink

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2401 Mounds View Boulevard * Mounds View MN 55112-1499 (763) 717-4000 * Fax (763) 717-4019 barb. benesch(i ci.mounds-view.mn.us www.ci.mounds--view.mn.us To be completed by Mounds View: Date Application Received: )f r ! Ca -AO) � ❑ NEW APPLICATION (never served) J�rRENEWAL APPLICATION ❑ APPROVED Date Term Expires: APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION Name: '�( .e 'e, Address: Z � Phone #1: City: /a(t State: Zip: y y / / Z Phone #2 Years this address: 5 - Years you have lived in Mounds View: - Email: /r • • •.Boa- ❑ Economic Development Commission ❑ Planning Commission (meets the 1st and 3M drool s 3Id Friday of each month at 7:30 am) Wednesday of each months at 7:00 pm) Parks, Recreation & Forestry ❑ Police Civil Service Commission Commission (meets the 41h Thursday of each month) (meets on an "as needed" basis) Experience and Qualifications Skills and Interests: IeV Employment, Occu ation or Other Relevant Ex erience: ✓o.. S /0/7 C'rJ Nr tG/ <' .P / ?40 Memberships, Accomplishment or Other Qualifications: t,✓ What is your main reason for wanting to serve on this Commission/Committee: TENNESSEN WARNING: The information provided by you on this. application will be used to determine your suitability for appointment to an advisory - commission, Participation as an advisory commission member is strictly voluntary and you are not required by taw to provide this information. However, should you not famish this information the City may have. difficulty determining your suitability for appointment, you regarding your information, and if selected, with your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is considered public information before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, prior - government service, veteran status. Once an ind;v�iddpal is appointed, the following additional items of data are considered public' residential address, - telephone number, email address. I have read naunderstand the T nn s can Warning and certify that the statements in this application are true and correct to the best of m knowledge: - - r Applicant Signature: Date: Your response to any of the ab6 a inquiries maybe 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.