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Roseville, MN - Officlal Website Page 2 of 2 I understand tha[ all information provided in ihis application, except my telephone number, fax number and email address, may be distributed by the City to the pubiic including, but not limited to, be€ng posted on the City of Roseville website. I agree to waive any and al3 cfaims under the Minnesota Govemment Data Practices Act, or any other appiicable state and federal law, that in any way related ro the dissernination to the public of information contained in this application that would be classified as pri�ate under such laws. I unders€and that I may contact the responsible authority for the City of Roseville if I have any quesiians regarding tha public or private nature of the ir�formation pravided.' � Yes I understand that the City will not publish my phone or fax numbers or email address without my authorization and do hereby allow ihe City to publish (check ail that apply). � Home telephone number � Work fax number � Work telephone number !� 6/1{ �' � Home email address � Oiher telephane number � Work email address � Home fax number Daytime Phone Evening Phone Cell Phone Hame Phone {if differen[) Work Phone (if dif€erent) Home Fax Wark Fax Home Email Work Email C �C �I� ? c � �. L �- �� `� 3�- �Jrz.�b 5tudent Application No if yes, please list your grada � o n� G L�✓dY2 0 Uv e b S; � � May we cqnlact you using your Ye5 work email or fax?* Tennessen Warning: Some or a!I of the infprmalion that yvu are asked Fo provide is classified 6y State faw as eEther private or confdential. Private data is information thal generally cannot he given ta the public, but can 6e given to the subjeci of 1he data. Confidential dala is informalion that generalfy cannot he given to either the pu6lic or Ihe subjecl oi the dafa. ihe City of Rose�ille is Collecting fhe informalion to determine quaEifications to serve on a Gilizen Advisory Commission. You are not legally requlred to provide Ihis information, However, if you do not supply ihe informalion, you may not serve on a Citizen Advisory Gommission. Other persons or entities aulhorized by law to receive this information are City Cauncil members, slaH, residents o( RoseviEfe and interested others. Any additiona! information may be emailed to info@ci.roseville.mn.us or deli�ered to Administration Department, City of Roseville, 2fi60 Civic Center Dri�e, Raseville, MN 55113 or faxed to 651-792-7030. i have read and understand the siatements an this form, and i hereby swear or affirm thaz the statements on this form are true. ' �Yes �� * indicates required fields. ,Submit. ;Submit,and Print Reset ;. Can.cel., Powered by CivicPfus � Copyright Notices Site Map � Disclaimer � Privacy Policy � 2fi50 Civic Center €Trive, Rosevilie, MN 55113 � 651-7RZ-706U http://www.ci,roseville.rr�n.us/foz-rx►s.asp?fid=237 1/7/2009