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Memberships, Accomplishments or Other Qualifications <br />been CL(k O� Cor^16VI► sf,., A <br />/1" in &• (2,4 1&1" i . <br />What is your reason for wanting to service on this Comm issionlCommittee <br />6e <br />%"� i'. r 4 � <br />1 v V <br />Please attach additional information if desired: <br />Choose File No file chosen <br />Optional <br />PRIVACY NOTICE: The infgrmauon prowdesl by yav on this 0pplicalydn will be used Io deiermrne your suilahrhiy for appo,niment to an advisory <br />nemn)r&Wrt. Pad 4palion as an advrsruy commission nlemher is sinctly veiuniary and yOu are net required by law to provide tha information However, shoWd Vrm <br />rsdt fumrsh Dust information the City may have difficulty determrnrng your suitahility for appcunlment, contacling you regarding yaw Information, and tf selecled, <br />rtoiify ng you of your duties on the advtsory commissiW. Under Minnesota State Statule t3.501, subd.3. the following inlarmat,on is considered public informatrfln before appornlment: name, ciky of residence, education and trarmng, employmenl history, vol"aer work, awards and honors_ prior government, service, vetera,l <br />siatus. Once an individual is appointed, the following additional items of data ase considered pukWC: residential address. teteptsone number, email address. I have <br />read and understand the T9nne55CaFT Warring and certify that the StetEmenis in this a0lc0001`1 arc Irue and cormcl io the best of my knowledge: <br />Applicant Signature <br />Date <br />Y YY <br />M M/OD,rYYYY <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 />212 <br />