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MOUNDS VI FAN 2401 Mounds View Boulevard * Mounds View MN 55112-1499 (763) 717-4000 * Fax (763) 717-4019 infoc moundsviewmn.orq I www.maundsviewmn.arq To be completed by Mounds View:} Date Application Received. c -q_ /cj ❑ NEW APPLICATION (never served) Xr RENEWAL APPLICATION ❑ APPROVED Date_ Term Expires: APPLICATION FOR ADVISORY BOARD/COMMITTEE/COMMISSION Applicant Information Name ,A 2i..i / ail le y i5 1� f A 96z-i L- Phone-9/ 3 ?i) 0Ur1 J5 Stat . / /� Zi% ` 2i / Phap/ Z z 7 76 999 Years h. ddress: Ye. s g6 have lived in Mounds View: Em. il:(f ►1 1[J 5 P /h /ri) 0- COM C /WI ( 1 Commission/Committee Applying For (If applying for more than one, please rank your preference with #1 as most desired) fl Economic Development Commission (Meets 3'd Friday of each month at 7:30 a.m.) ❑ Parks, Recreation & Forestry Commission (Meets the 4`h Thursday of each month at 6:30 p.m.) Comprehensive Plan Taskforce 1%Planning Commission (Meets the -V' and 3'd Wednesday of each months at 7:00 p.m.) ❑Police Advisory Board (meets on an "as needed" basis) I Other ❑ Experience and Qualifications Skills and Interests: 01.0 91A-wvi -r- Ft,u� Co 044— col Employment, Occupation or Other elevant Experience: g,Q' '1 Memberships, Accom.lishments or Other Qualifications: What is your main reaso for wantin to serve on this Commission/Co ttee: TENNESSEN WARNING: The information provided by you on this application will be used to determine your suitability for appointment to an advisory commission Participation as an advisory commission member is strictly voluntary and you are not required by law to provide this information. However should you not furnish this information the City may have difficulty determining your suitability for appointment, contacting you regarding your information, and if selected, notifying your of your duties on the advisory commission. Under Minnesota State Statute 13.601, subd.3, the following information is considered public information before appointment: name, city of residence, education and training, employment history volunteer work, awards and honors, prior government service, veteran status. On n individu appointed, the following additional items of data are considered public: residential address, telephone number, email address. I have nd under the Tennessean Waming and certify that the statements in this application are true and correct to the best of my knowledge: Applicant Signature: Date: 7( Your response to any of the alcove 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 City of Mounds View is committed to the policy that all persons shall have access to its programs, facilities and employment without regard for race, ethnicity, gender, age or physical abilities.