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City of Mounds View • 2401 Highway 10 Mounds View, MN 55112 (612) 717-4000 Application For Advisory Boards and Commissions Group Applied For: `'""ar KS Gm:.-,1 I1errectt,o,+_., 7,oni6'1l 5Si O Ik_) Full Name (Please Print): Ii i K e S zc Z c p a,0S K r Home Phone: 176 ` 17 9 Work Phone: 5 " 5 6 41/4f Address: a 335 kapo`r Years at this address: /5 Years you have lived in Mounds View: /7 Email Address: /715z e 6,4-AA7,6 c$1 • .li ' a is • W. i • h.v- h- . •r .no • _ it C• . i•.- : • Skills and Interests: y 670/#0 /l L /S:�G' .? // SLY !r ma »c // e� *— /�D r cf ' e4.-¢//— /tie /34r ei., 5 �f' L/i / /J.ae_ ✓°i, -div t- A e s9 /41 r472.A et' c_ ,Po, , v s /moi / t'c Employment, Occupation or Other Experience: 5'r4 J 5 41 Illy s{5 ,a-1 r 44'.� / �M- /3/r�IL/ L-L "Rh! .4.t.73'` �p `fi e.�v,- Z.. lZ (- u 5721.'1"-17 i 21.•,"-17 Memberships, Accomplishments or Other Qualifications: .27 /f'vc. ,g-nn a.' e. t 1 7 /V, 77 / /4"?' ,f7eri //' /d . ,e, .,,Pa-r7r-/ v tVex - e ae7/5 /W.c ./V SSL ,%sie e s - Please state your reason for wanting to serve with this group: J > e 7o Ses ✓iiics/tcis L`'-zE2,, ex,7T s- /Iv /4/y 4 1 e v a( �' /'/'c'� �t s .az)/2 6 4,4- e u r3 . ''7 a/w .�s i %j keds �4 ,5 / 'y 4,/14 14,.a/r/41. i /'€e£,64 7-1 c.z.i /Pa n 77% �� .�./ Date: (; Signature: . • C. - �' ��—�G'-1 / [Your response to a y of the above inquiries- ay be continued on the back of this form and you • may attach any other material that you would want the Mayor and 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,creed,color,sex,age national origin or handicap.