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<br />Other Comments: (Include any further info,., lation you would like the CIty Council to consider or
<br />that you feel is relevant to the appointment you are seeking. You may also attach other materials you
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<br />would like the Council to consider.) I b,tI;"L'G #VA T uuu1..l ,t:)rlJ()I'dt. IAV\~(,tq pr>:>.ch',:;>>!1
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<br />Tennessen Warning - Some or al the informa IOn that you ar as ed to provide is classified by S ate law t s either private or
<br />confidentiaL Private data is information that generally cannot be given to the public but can be given to the subject of the data.
<br />Confidential data is information that generally cannot be given to either the public or the subject of the data.
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<br />The City of Roseville is collecting the information to determine qualifications to serve on a Citizen Advisory Commission.
<br />You are not legally required to provide this information. However, if you do not supply the information, you may not serve on
<br />a Citizen Advisory Commission.
<br />
<br />Other persons or entities authorized by law to receive this information are City Council members, staff, residents of Roseville
<br />and interested others.
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<br />I understand that all information provided in this application, except my telephone numbers, fax number and
<br />email address, maybe distributed by the City to the public including, but not limited to, being posted on the
<br />City of Roseville website. I agree to waive any and all claims under the Minnesota Government Data
<br />Practices Act, or any other applicable state and federal law, that in any way related to the dissemination to the
<br />public of information contained in this application that would be classified as private under such laws. I
<br />understand that I may contact the responsible authority for the City of Roseville if I have any questions
<br />regarding the public or private nature of the information provided.
<br />
<br />I understand that the City will not publish my phone or fax numbers or email address without my authorization
<br />and do hereby allow the City to publish (check all that apply).
<br />
<br />_home telephone number
<br />_work telephone number
<br />_email address
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<br />/'.'-b-......., . ~;$';1""""----"
<br />Signature of Applicant
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<br />Date of Application
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<br />Application 031017
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