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I understand that the City will not publish my phone or fax numbers or email address <br />without m� authorizaC�on and do hereby alZow the City to publish (check all that apply).: <br />Hame telephone number, Work telephone number <br />Daytime Phone: <br />Evening Phone: 651-646-8198 <br />Cell Phone: <br />Home Phone (zf different}: <br />Work Phone {if different): 651-748-2256 <br />Home Fax: <br />Wark Fax: <br />Home Email: <br />Work �mail: <br />Studen� Applica�ron: No <br />If yes, please list your grade: <br />May we �ontact you using your work email or fax?: Yes <br />I have xead and understand the statements on this form, and I hereby swear or affirm that <br />the statements on this form are true. : Yes <br />Additio�al rn�armation: <br />Form submitted on: 2/11/2049 9:16:57 PM <br />Submitted from IP Address: <br />Form Address: http://www.ci.roseville.mn.us/forms.asp?FID-237 <br />2 <br />