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City of Mounds View <br />2401 County Highway 10 <br />Mounds View, MN 55112 <br />763-717-4000 <br />AR„ai�,kation for Advisory Commissions and Committees <br />Group(s) applied for: P fro 1-V <br />Full Name (Please Print): <br />Work Phone:-1�Q 9 � v Work/Cell Phone; <br />Address: U 3 -5 S N%as4mL v�- <br />Years at this address: q. Years you have lived in Mounds View: I 7' 5— <br />E -mail Address: k�.e, s Y1i • ccr <br />EXQeriience and Quailfigati_ ons <br />Skills and interests: its : 'asf su io �����R , 615 �'e, <br />r/� ,1� � r.. ,,•(,e�i�cMFm�t�c..�.� � 1+;� <br />f alk 4 t�+a c i, (X . <br />Employment, Occupation or Other Relevant -Experience: <br />Pr <br />ct <br />j �,�.,� <br />Memberships, 'Accomplishments or Other Qualifications: <br />iy"t to'vcvsi� � 20f3 �pIS <br />Please stat our reason for wai to serve with this group:, <br />num i�ut,�4tcc '?yV '44 (off la <br />Signature: - --- Date: 0 t, 1 <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 commuted to the policy that all persons Shall have aOOS$ to its programs, <br />fadI les and employment without regard for race, ethnialty, sex, age or physical abilities• <br />