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Eke Gly Vii_ <br />.1 �,r� �t� dn,� on•�a �.� try r�'� moo+ ju?� a� I i�av� ... _ _ <br />d tin go maa Rl&s Co mrii%s AL%q, I crone Inch in vim+ mkE r aa� learn <br />Wrd3Mt 1 Of perMad :k �1L � 1 r ak�1C alr -6 ire <br />llaaavwiFFe� - - —• -- — <br />omc trr th irtfcrcmatsc�n - - 'ai to prtrviiicljr tat late as eitiwr private or <br />la tk AWNWO" #Waft Wet% at t da}a <br />ka4n=ME OW t =max MV11= In ddw UW pvblec, vt dw, d-PL-L. <br />The City of PWM a co lc Wng Elie int'orna Won b ilk` z gail;-MOM— to serve en a Cliin Advisory C© Mission. <br />You axe not leplly Rq&50 to provided4s Wrorawtion_ Flowever, ifyou do= supply M 05vx4taL you may nor serve en <br />a Citizen Advisory Connnission, <br />{ IW-J peXnrl, Gl M161le7 J5 [)Mrs by l&V 7,0 OWaIVC 1hL� dftbFMMbm M C dJ willQ <br />aIJ i '3trJ --r d IdM <br />I unerstand that infxrradxomt -provided in this app except my telltonetnbers, ftuc number jQ <br />email address, maybe distributed by the City to thelic including but not limited to, being posted on the <br />City of Raseville websde< I aWeeto waive any and all under the Minnesom Gomment Data <br />Practices Act, or any other applicablestate and federal law, that in any way rel4w to the dissemination to the <br />public of itafarmation c ntairted i n #1u ap_Lation # wow be r assilteal as private under such laws- I <br />and that I may c,* the, mp mvzle iiy for the City ofkoseviile ff I have any questions <br />3 U�n& the public or private nature of the inform provided, <br />I understand that the City will not publish my phone or or emait address pM my authorization <br />and do hmby allow tho City to publish (check ill that apply). <br />home telephone number work telephone number X (yell nn 1 tether telephone number <br />_home fax number work fax number (651-207-9769) <br />home email address work email address <br />Signature of Applicant Date of Application <br />