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2021_0125_CCPacket
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2021_0125_CCPacket
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1/13/2022 1:40:37 PM
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1/13/2022 1:40:18 PM
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Roseville City Council
Document Type
Council Agenda/Packets
Meeting Date
1/25/2021
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Occasionally, City staff receive requests from the media or from the public for ways to <br />contact Commission members. The Commission roster is periodically made available. Under <br />Minnesota Statute §13.601. subd. 3(b), either a telephone or electronic mail address (or <br />both) where you can be reached must be made available to the public. Please indicate which <br />contact method the City may make available for inclusion on the Commission roster. <br />1. Home/Cell Phone <br />2. Email Address <br />35. Background Authorization* <br />I understand that the Commission position for which I am applying may require the City of <br />Roseville to perform a background check. As a result, an investigation may be made in which <br />information is obtained through personal interview(s), information held by law enforcement <br />or governmental agencies, present or former employers, financial institutions, or references I <br />have provided. I understand that the City of Roseville will use the services of the Roseville <br />Police Department to assist with the research and verification of the information I have <br />provided on my application. The City of Roseville will utilize various sources of information it <br />deems appropriate, including, but not limited to, credit reporting agencies, Department of <br />Motor Vehicles records, criminal conviction records, current and former employers, military <br />records, education records, and professional and personal references. I request, authorize <br />and consent to the release and disclosure of any and all information, including, but not <br />limited to, the above to the City of Roseville and the Roseville Police Department, and hereby <br />expressly release any person who provides information pursuant to this investigation from <br />any claims or liability by me or on my behalf. <br />1. Yes <br />36. Acknowledgement* <br />I have read and understand the statements on this form, and I hereby swear or affirm that <br />the statements on this form are true. <br />1. Yes <br />37. <br />38. <br />1. Receive an email copy of this form. <br />39. Email address <br />This field is not part of the form submission. <br />40.Submit Submit and Print <br /> <br />
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