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City of Mounds View <br />2401 Highway 10 <br />Mounds View, MN 55112 <br />(763) 717-4000 <br />Application for Advisory Boards and Commissions <br />Group Applied for:_ nd <br />Full Name (Please Print): Vc� vvr\ <br />Rome Phone: _19 Q - I U Work Phone: 57 <br />Address: <br />ll <br />Years at this address:. Years you have lived in Mounds View: <br />E-mail Address: <br />Qualifications You Want to Have the Mayor and CLty Council Consider: <br />Skills and Intere ts- e,7' - �m <br />-6 tf,� A- V\�Q- C— L <br />knUCAV C,_,,. <br />Employment, Occupation or Other Experience: <br />Memberships, Accomplishments or Other Qualifications: <br />Please state your reason for wanting to serve with this group: <br />Signature: Date: <br />(Your response to any of the above inquiries may be continued on the back of this form and you <br />may attach any other material that you would want the Mayor and Council to consider.) <br />The City ofMounds View is committed to the policy that al! persons shall have access to its programs, <br />Facilities and employment without regard for race, creed, color, sex, ago national origin or handicap. <br />