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PL—PCS—KySylycz,yn From : support@civicplus.com Sent: Monday, February 28, 2011 4:20 Pm TO: Carol yn Curti ; M�argare�t Cirri scol 1 Subject: online Form Submittal: Com�m�ission Application—PL—PCS—KySylycz,yn The following form was subm�itted via your websito: Commission Application Please check com�m�ission applying for: Planning Commission,Police civil Service Commi ssi on If tithe r, please list name : This application is for:: New Term If this is a student application, please list your grade : Name :: 3ohn KySylycz,yn Address:: 3,083, Victoria Street City, State, Zip: Roseville, MIN 55113 Phone Num�be�r:: 65148413,84 Em�ail address:: j ehn ftsel uti ensl l e . eery HOW many years have you lived in Roseville ?: 20 work Experience (especially as it relates to the Com�m�issien /Beard for which you are applying): will discuss during inte�rvieau Education:: will discuss during interview civic and Volunteer Activities (Past and Present):: will discuss during i ntervi ear Please state your reasons for wanting to serve on the Commission/Board:: will discuss during interview what is your view of the role of this Commission/ Board?: will discuss during i ntervi ear Any further inform�ation you would like the city council to consider or that you feel is relevant to the appointm�e�nt or re�appointm�e�nt you are se�e�king.: will discuss during interview I understand that inform�ation p nevi deed in this application ray be distributed by the city to the public including, but not lim�iteed to, being posted on the City of Roseville we�bsite . I agnee to waive any and all claims under the Minnesota Gove rnm�e�nt Data Practices Act, or any tithe r applicable state and federal law, that in any way related to the dissem�ination to the public of inform�ation contained in this application that would be classified as private under such laws. I understand that I ray contact the responsible authority for the City of Roseville if I have any que�stions re�garding the public or private nature of the inform�ation provided.: Yes occasionally city staff gets requests from the media or from the public for ways to contact Commission members . The Commission roster is periodi cal y made available. Please indicate which inform�ation the city ray release to someone who requests it or that may be included on the Commission roster. Under MIN statute §12.601. subd. 3,(b), e�ithe r a telephone or e�le�ctronic m�ail address (or both) where you can be reached rust be made available to the public. Please indicate at least one phone number or one em�ail address to be available to the Page 1