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Evening Phone: 65I-487-2357 <br />Cell Phone: <br />Home Phone {if differentl: <br />Work Phane (if different}: <br />Home Fax: <br />Wark Fax: <br />xome Email: tomelund@aol.cam <br />Work Email; <br />5tudent Applicatian: No <br />�f yes, please lis� your grade: <br />May we contact you using your w�rk email or fax7: Yes <br />� have read and understand the statements an this form, and I here�y swear or affirm that <br />the s�atements on this form are true. : Yes <br />Additional Information: <br />�orm submitted an; Z/29/2fl09 5:04:46 PM <br />Submi�ted trom IP Address: <br />Form Address: http://www.ci.roseville,mn.us/forms:asp?FID=237 <br />2 <br />