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Memberships, Accomplishments or Other Qualifications <br />b & n C�&Ifk Or GO4,]h, sflo, A <br />✓114 m. &11 O� yea'(f . <br />What is your reason for wanting to service on this Commission/Committee <br />6( ,(r —)� 4 <br />Ic J, C �jr� t, t• �i r <br />�. U / <br />Please attach additional Information if desired: <br />Choose File No file chosen <br />Optional <br />4 PRIVACY NCTICH: The Wonnauon providod by you on IhIs application wIII be used to dalermime your suit abiIlly tar appointment to an advisory <br />commission. Participation as an advisory commission member is stddly voluntary and you am not required by law to provide thta Informalion. However, should you <br />not furnish this Inkxmallon ute CIly may have dlificully determining your sultabilRy ror appointment, contacting you regarding your lnfarmallon, and If selected, <br />notlfyino you of your dulios on the advisory commission. Under Minrasata Slate Statute 13.801, subd.3, The following Information is considered public information <br />before appointment: nama, city of roWdance, educsiton and tralnIng. employment htetory, volunteer work, awards and honors, prior government setvmre, valoran t status. Once an individual is appointed, the following additional items of data are considered public: residential address, tolephone number, email address. I have <br />read and understand the Tennessean Waming rsnd certify that the sialements In this appllcatlon are true and correct to 1110 best of my knowledge; <br />Applicant Signature Date <br />MM/DWYYYY <br />Format: MM/DDIYYYY <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 />;ubmil <br />t <br />2/2 <br />