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MOUNDS1ViEw <br />City of Mounds View <br />2401 County Highway 10 <br />Mounds View, MN 55112 <br />763-717-4000 <br />Application for Advisory Commissions and Committees <br />Group(s) applied for: (f0V"m ;SS _% ov-) <br />Full Name (Please Print): Sr,,,,&An 6 tccwsCV7 <br />Work Phone: W-) Worldoellhone: Gsl- Z 3S - 60sz <br />Address: Q?J. AAWO , I_jZCL=j M-A) �M f �- <br />Years at this address:_ Years you have lived in Mounds View: Z� <br />E-mail Address: _ lac I�,��Gv�,[y]�a_;_1, c�v✓\ <br />Experience and gualifications <br />Skills and Interests: <br />Lego( 'qeswc k A-,J wc._6NS <br />Ir��rnt <br />Empldyment, Occupation or Other Relevant Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />kAmvica63ti- S4u1 3c� s4ssoc;�F�ct� <br />t{ RLACPM COWAt -( l �{ Ssac:ot��✓1 <br />Please state your reason for wanting to serve with this group: T <br />ck�. t,, S<<uc yviC�nuv� �y, L A��(�cG C(�crk� (G►M,5s7n <br />Sw� Cn weecA u�Q�(i I �+^a f ''i"Gen. wd Ic&l 6,cK6,,,, ,,d [ate Cc 6-F <br />Signature:-J Date: 1 Z s <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 persons shall have access to its programs, <br />facilities and employment without regard for race, ethnicity, sex, age or physical abilities. <br />