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Memberships, Accomplishments or Other Qualifications <br />b et ►1 C 4 &Ak Olt Co o, t-v► t 31 i A , � �)u ryt 12v✓ O� r �s� J - <br />What Is your reason for wanting to service on this Commission/Co fmmittee 114,1 <br />I <br />Please attach additional information if desired: <br />Choose File No file chosen <br />Optional <br />PRIVACY NOTICE: The information provided by you on this application will be used to determine your suitability for appointment to an advisory <br />commission. Participation as an advisory commission member is strictly voluntary and you are not required by law to provide this Information. However, should you <br />not furnish this Information the City may have difficulty determining your suitability for appointment, contacting you regarding your Information, and if selected, <br />notifying you of your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is considered public Information <br />before appointment: name, city of residence, education and training, employment history, volunteer work, awards and honors, prior government service, veteran <br />status. Once an individual is appointed, the following additional Items of data are considered public: residential address, telephone number, email address, I have <br />read and understand the Tennessean Warning and certify that the statements In this application are true and correct to the best of my knowledge: <br />Applicant Signature Date <br />J:;� •I - -`Zo." <br />MMII DiYYYY <br />Format: MMIDDIYYYY <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 />Submit <br />2/2 <br />