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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: .I� �(�e C ©�,- rY, r j <br />Full Name (Please Print): <br />Home Phone: r �� ��. Work Phone: <br />Address: _ � r,\ WO -0t> <br />Years at this address: 2p ____—,Years you have lived in Mounds View: _z <br />E-mail Address: I � � 9 a _ M � "i - C O tM <br />Qualifications You Want to Have the Mayor and City Council Consider: <br />Skills and Interests: (,)i4c 1jSS P `'4' ( A�j1 6,D I r� ,? ) e,,-,/�� r �'r <br />-Z6 L IUs 3j�) �icr y6u4. nem to <br />r 0) 4 l-2 fib, An-�- <br />Emp oyment, Occupation or Other Experience: A" 0S � �0�` �J G)e e,? a <br />Memberships, Accomplishments or Other Qualifications: <br />r =f r <br />Please state your reason for wanting to serve with this group: <br />�✓�I GS/ilUf fUY cur r� <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 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, creed, color, sex, age, national origin or handicap. <br />�n_1g-06 P01:[E1 IN <br />