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Memberships, Accomplishments or Other Qualifications <br />bor n C r' ^l ('Ak or IY� ►y� 1 Sf t o �. <br />11,4 -n 12R" ()l fA,( > . <br />What is your reason for wanting to service on this Commission/Committee <br />C'r)4'y7W Inz, AIV ivbv <br />1<1 <br />Please attach additional information if desired,. <br />Choose File No file chosen <br />Optional <br />PRIVACY NOTICE; The Informalton provided by you On Ihis appllGation will he used to determine your suitability for appointment to an advisory <br />❑ommissinn. PartirlpalfOn as an advisory euminlssion member is alfidty vaturilary and YOU are not requl red by Iaw to provide this Information. However, shatdd you <br />not fumish this information the icily may have difficulty dalerrnhing your suitability for appointment, conlacting you regarding your Infdrmallon, and if seteoed, <br />notifying you of your duties an the advisory commission. Under MInneswa Stairs Statute 13.001. subd_3, the following information i%considered public lnformatinn <br />befute appointment: name, icily Of resideisco, education and training, emploympni history, volunteer wniit, awards and Iit) nors. prior government Service, veteran <br />status. Once a individual is appointed, the following additional items of dala are considered public: residenlial address, lelephone number, emall aiWress I have <br />read aitd underslond the Tennessoan Warnlny and certify Via[ the statements u5 Ihfs applIcalion are true and coreeict to ilia hest of my knovrledge: <br />Applicant Signature Date ; y <br />MM/DDiYYYY <br />Format: MM/DDlYYYY <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 <br />for race, ethnicity, gender, age or physical abilities. <br />2/2 <br />