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MOUNDS.VIEW <br />2401 Mounds View Boulevard * Mounds View MN 55112-1499 <br />(763) 717-4000 * Fax (763) 717-4019 <br />it;irb.benesch o_j moundsvrewmn.osy <br />www.tno to svrewmi.o[g <br />H L7U5 Vi State: M>j <br />ears at this address: <br />Email: IY11-nseyer son @ ^ <br />�'�C]O, Cpt'Y7 <br />To be completed by Mounds View: <br />Date Application Received,._______ <br />❑ NEW APPLICATION (never served) <br />❑ RENEWAL APPLICATION <br />❑ APPROVED Dnte___-_.._ <br />Term Expires:----------------------- <br />Zip: 515111 ?- <br />Years you <br />Phone #1: <br />Phone #2 <br />lived in Mounds View: <br />M Planning Commission (meeta the td and 3b <br />Economic Development Commission Wednesday of each months at 7:00 pm) <br />(meet$ 3,d Friday of each month at 7;30 am) Police Civil Service Commission <br />Parks, Recreation &Forestry Commission (meets on an "as needed' basis) <br />(meets the 4P Thursday or each month at 6:00 pm) E Comprehensive Plan Taskforce <br />Skills and interests: V() <br />— i 4AJL. -i t nn <br />Em to ment, OCCU etion or Other Reievant EXOerlen <br />t <br />Membershl s Accom Ilshment or Other Oualfficalion <br />What is your main reason far wanting to serve on this <br />i twrrtSsttY WARNING : Tha inFnmigtiwr prnvlderl by you on this OPPU""On w}H he usrsd lndetennlne your suitahility fqr appolnn>7enr tq an advisory <br />cornmisston, Participation as an advisory cvmmleeign member is slrf0 valuntary and yuu are rtp[ required by law [tr gravlde t" ininrmaGen Flowever. <br />should you not furnlgh this Infvrrr[atiorrlhe City ntay hnym dllileuliy detemrining your a;uitshlhly Tor al}poInbttgnt, cgntacring yuu regardlnq your infonrsurion, <br />and Hseiectad, vdth your dunes on [he advisory nammisstgn. Under Mlnnesola Stale 5ttttutc 13.6U1, subd,3, the i0k�yritag lefnrmalion 1s a anlidarod <br />public information before appointment: name, city of rosldnnca, education rsnd treln{nQ, enlpluNnrfrrt lustory, vgluivaer work, awards and Honors, prior <br />Wvernntent survim, voter ran status. Once en individr�al #s appglnred, the Inllnvring addltlo,"HI: <br />its of dots arr consldared publit residerttfat nddreo,, <br />retrirHone number, email address. {have read and understand Iht Tennessean W, 9 and :edi[y that the stetemen[x In thin aul>lical}Wt are two anti <br />ciXfoel to tite best of my knuwtxcroo <br />licant Signature: <br />Date: <br />Your response to any of the above Inquiries may be continued on the back of this form and you may attach other information <br />that you would like the City Council to consider, <br />The City of Mounds 'flew is committed to the policy that all persons shalt have access to Its programs, facilities and employment without regard for race, <br />ethnicity, gender, 090 urphys}cal ohAMes. <br />