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i <br />DEC -13- 2006 -WED 12:04 Phi YOST& BA ILL <br />FAX No, 6123441689 <br />=Uv w bu mrvt v of tke role of [leis 0'x dk" [t <br />It has not changed <br />P. 002 <br />Other Comments: (Include my.,ft. Iher- information you would like the City Council to consi&ror <br />t. .b relevant to F4- appolmmeni: Yo;r m7 also attach other materialKyou would like the <br />1 Council to consider.) <br />i — — <br />- & &en NVam! rig - �stl r ur�u�ti�ttt i C4 ,.;rle i.% <br />otag ' <br />c�denhaL �rr� ova 14 ; irk �G 9011 <br />Confidentialdata is' n it von that g�uermlly cmmm be given to either- the �ba or the subject of the data. <br />The i :r of Roseville, is Collecting the informationto determinequalificationsto serve on a CIMMAdvisory Commission. <br />You are not legally requiredto provide this idormatiom. However, if you do not supplythe iuf oration, you may not serve on <br />a Citizen Advisory Commission. <br />Otherpersons or entities authorizedby lawto receivetbk informationare City Council members, staff, residents of Roseville <br />and intareste others_ <br />I iio3 that all �ttCa provided in tbig application, except mytelephonenumbers, fax numbex and <br />e=U address, may be distributed by the City *to the public but not limited to, being posted on the <br />City of Roseville website. I aF= to waive any iO E clams wdu the Govemment. Data <br />Practices Act, or any other applicable state and federal law, ;%R ia any way related to the dissemination to the <br />public of information W ffus that would be as under swll laws. I <br />underswd that I may intact the responsible authority for the City of Roseville if I have arty questions <br />x10 public or private MUM of the information provided. <br />I understand that the City -will not pru my phone or fax numbers or cmail address without my authorization <br />and do hereby allow the City to publish (check all that apply). <br />home telephone number --k telephone number other telephone number <br />_home fax number X worry fax number <br />_Z home email Ras, work =0 add ress <br />Applicant <br />Date of Application - - <br />