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D*chea- Carnane®tc: (Include any further information you would like tlzA City Council to consider or that you feel is relevant to tlee appoitatment you are seeking. You may also attoch other materials you would like `he Council to consider) ~~~~ rM t" vt 'r'v7 - Yr n '~~ . , 1, ,,,-i~ ~'';~ r'--vu-~, Tennessee warn5ng - Some or all the information that you are asked to provide is classified by State law as either private or confidential Private date is information that generally cannot be given to $ae public buY cau be given to fire subject of the data. Confidential data is iniormation that generally cannot be givea to either the public or the subject of the data. The City of Roseville is collecting the information to determine quali5ca4iw-rs to serve on a Citizen Advisory Commission. You are no4 legally required to provide this information. However, if you cio rot supply the information, you may not serve on a Citizen Advisory Commission. Other persons or entities authorized by law to receive this information are City Council members, staff, residertfs of Roseville and interested others. I understand that all information provided in this application, except my telephone numbers, fax number and email address, may be distributed by the City to the public inciudtng, but not limited to, being posted on the City of Roseville website. I agree to waive any and all ela.ims under the Minnesota Government Data. Practices Act, or any other applicable state and federal law, that in any way related to the dissemination to the public of information contained in this application that would be classified as private under such taws. I understand that I may contact the responsible authority far the City of Roseville if I have any questions regarding the public or private nature ofthe information provided. I understand that the City will not publish any phone or fax numbers or email address withaut my authorization and do hereby allow the City to publish (check all that apply). -home telephone number work telephone number -other telephone number home ~x number work fax number Thorne email address work email address Date of Applicat on AppNcmiars 061129 '~J~s~>t €a ye~~ v~ ag t~~ r~IrV o~ t1~s C.nc~ffiotcl~arnrni<tteeZFasls tcssee?