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1/10/2015 13:50 FAX USDAFORESTSERVICE <br />0001/001 <br />MOUNDS ViL • <br />City of Mounds View C (J�(� Q/ <br />2401 County Highway 10Q <br />Mounds View, MN 55112 <br />763-717-4000 / <br />Application for Advisory Commissions and Committees <br />Group(s) applied for: <br />Full Name (Please Print): cS�y-L /`'q �d V a c r <br />Address: ayol A�0111uao,4 <br />Years at this address: Years you have lived in Mounds View: l _ <br />E-mail Address: /�c4V1 cA <br />Exoerience and Qualifications <br />Skills and Interests: ,Z � v� of BS � � "�-' ��� ��`��,G►�. <br />Employment, Occupation or Other Relevant Experience: <br />& dlu I d _ a, !� , )[:�ves;�- 51 r -v; ?.—_ M 2 rV rS . n SSS oy1 <br />Memberships, Accomplishments or Other QuZifcations: <br />Please state your reason for wanting to serve with this group: <br />tic lQGo,- �'►/�' e.S�f Ne <br />Our�,�o �i� /du�+dS ��u� <br />Signature: Date:6 <br />(Your response to any of the above inquiries may be continued on the back of this form and you <br />may attach other information that you would like the City Council to consider.) <br />The City of Mounds view is committed to the policy that all parsons shall have access to its programs, <br />facilities and employment without regard for race, ethniclty, sex, age or physical abilifies. <br />Received Time Nov,10. 2015 1:47PM No.2546 <br />