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'a MOUNDS I EWV 2401 Mounds View Boulevard * Mounds View MN 55112-1499 (763) 717-4000 w Fax (763) 717-4019 hails-ktencsclt olmo>rrtclsviewrnrt.oM Name: CRY' Muy VI,State: fA rj Years at this address: Finaii: mmse�er�son @ .,, moo, cc)rY-) To be completed by Mounds View: Date Application Received: ,,,,___.,__— ❑ NEW APPLICATION (never served) ❑ RENEWAL APPLICATION ❑ APPROVED Date_••_____________ Term Expires: --------___ Zip: 55 f 12 i Phone #2 Years you have lived in Mounds View: Planning Commission (meets the 1" and 3b Economic Development Commission Wednesday of each months at 7:00 pm) [](me a* 3" Friday of eech month a17:30 em) � Police Civil Service Commission Parks, Recreation & Forestry Commission (meets on an "as needed' basis) (meats ttse 4111 Thursday of each month at 6:aa pm) D Comprehensive Plan Taskforce Mi or Other Qtialificalions- Is our main reason for wantinr� to serve an this e snrvtastry WA$1 VINEl; Tha Irsfurrnatlntr pravrrind by YOU an this applicntfan will ha uat d trs datanminn your stliiuhllily for srppoiniruent to an advisory Conursl3slcu. Purtioipallon as an advisory commiscion member Is stnctly voluntary and you are not required Gy lawto provide thla Inlarmahon However, ahould you nor furnish this Irrfor►imbon The City may have riiffleulty rletemrining your suitability ier el}pafnrmant, canfrlcdny you regarding your inHowever, and if selactad. Willi your duties on nc� advisory nrnrnlrrston. Under Minncaoro stale statute t3-601, sulsd,3, the foltordnp mfoirnallon iu considered public Information before appointment: name, city of residence, education undtrain[n0, emptoyineur hialory. volunleur work, awards and honors, prior government service, veteran Status. Once an individual I. appointed, tine followlnli addliforlul items of date ure oorisidored public- re,ldentia{ addrnsa, telelthomr number, [mall address. I have read and undnrstand lt1t, Trine+sewn Warniny Mill e:erllfy that rile stnraments In thiq atsp]Icauun are iron and Caire'll le the bast of env knowltiarip• icant Signature: Date: S 1 Your response to any of the above 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 0111y of Mounds view Is commiftad to the policy that all persons shall have access to fts programs, facilities and employment without regard for race, ethnicity, gender, age orphyslcM abilities.