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STA,E OF IMFr.;50T1 <br />D,2MTii14T OF FJDLIC W.FM <br />_ DIVISIOR OF ';i1MZICY STI IC?.S <br />�TYIu OR PRINt DJ IDT' B-5 Stato ca;+:iol TTORT.UaT: 10TIFY THIS <br />St. Paul, llnrosota 55155 rfIC3 0F�Utt <br />APPLICATION FOR 'LNQq—L HCY UU11(U_u_l1' �ASSIS+l'.'uaCL <br />1. Name of Civil Defense Agency: Sity of Mounds View 2, Address: 2401 Hwy. 10, Mounds Vt&sota 55112 <br />S. Political subdivisions settved by this agencye Ci_y of,Mounds _View�- <br />4. Has Loyalty Cath been administered to Civil Defense Director? X+ Yes No. <br />F1J4°+: The Walty Gath is required from all personnel beforo enterin'u on duty. In accordance with 141nneeota Law, <br />all people serving in a Civil Defense capacity are required to ta:x the loyalty Oath, regardless of whether <br />or not they an being reimbursed from &mergency Ihnagownt Assistance Funds, <br />5. Has Compliance to Civil Rights been filed (D)CPA Form 056)? . al X Yes Dto <br />6. Has Civil Defense Director satisfactorily continued his professiondevelopment? ,X Yes --No <br />No <br />Is the Basic &argency Flan completed, approved, and up to date? R, Yes __ No <br />BeS. Regional Director Date — �- <br />0. life agree to abide by State Travel Regulations X Yes No. If no, attach 3 copies of Regulations governing your travel <br />9. Ile agree to abide by Cir,1-3 on Travel and A11 Other'%D Yes ,_ No, If no, attach justification for exceeding 5% <br />Travel and 32;b All Other. <br />10- Canary population! r12,979 (Year 1989 Lsti.msted current population: 12,593 �9 <br />Tl. Based on 40 hours per weok, give percent of time you are employed with Civil Defense 50 ., <br />12. 7rnn• m of vem w,!imram.- _�------- FuDEU SHAR3 FOR FISCAL WR 19 <br />,LULL MICE I ! )v Ur P yr <br />Tri•EC Ila TOTAL Fi1tSONFIe`7____f TOTAL TIi�P~3 TOTAL_ OTHER I TOTAL TOTAL <br />! 1 0 j 1 ;' 3,179.50 97 15 _ .5 67.50 ; 2.5 3,262 <br />lfo are atraro of the flood insurance purchase requirements of tho Flood Disaster Protection Act of 1973 (PL 93 234 arur. the <br />Federal Insurance Administration Rnjulationa. <br />If,' certify that thn rennestad funds are true and just and reflect onky tho Federal share. lie further certify that <br />local -.funds will be availablo in the amount of o 17,736 to match this request. <br />Signed by: Date: _ _ _S> ned by: Date: <br />ihyor or Cl+��*� of Bocrci� _((Tv-d Defenso Director) <br />MP5-dTS AD-6 zs7 Rov. it-5-31 APP JDIX - 1 <br />