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CCtervi le <br />CITY OFCENTERVILLI <br />APPLICATION FOR APPOINTMENT <br />Comrnittee/CommissionlEDA applying far: <br />NAME: �C�s r s a. '�, m+ C V1 E-5, <br />STREET' ADDRESS: l a ICJ a L q VaL III Dr i Y e. <br />CITY: CC-11tCY'Vi /%0-- ,MN zIPCODE: 5�0JP <br />H0ME T LEPH0NE:(AS1T 1/F ` 1 A9s' WORK TELEPHONE; <br />FAX: FmAii. ADDRESS: 6) BLA-A Kt ,C'A <br />Number ofyears a Centerville Resit',: c�, Number of years Centerville Business Owner7: <br />Are you presently serving on a Centerville Committee or Commission?: flo <br />Whig One?: Test?: <br />Have you served on a Centerville Conunitiee or Commission in the past?: PQ <br />Which Ow?: Term?: <br />Which Cue?: Term?: <br />What do you have to o�R"er _&ee City of Centerville as a Committee or Commission member?: 47,&e� <br />CAAA, ,mod Ouk— <br />� + l;xprrience or Edueation that would enure yarn effectiveness as a Comradtac or Commmmm memberiz . <br />Signat Date: <br />Return to: City �AA�,�istrator <br />City of Centerville OR <br />1880 Main Street <br />Centerville, MN 55038 <br />