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<br />Other Comments: (Include any further info��nzation you would like rri _� ���'�� C�r ��rrr :�;' to � ��� i: rr� r�� � or
<br />i1�.czt you feel is releva»t to re- appoi��.tnient. You rr�ay also attaclz otlae�� n�ate�°iczls you would lilze the
<br />Council to consider.)
<br />A � t. s �;ti � X, � �L'J G� � r�C•� 4� r� Sl�'i�1���� ���ra�
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<br />Tennessen Warning -�••il� or all the information ;I:.�I you are asked to provide is classified by State law as either private or
<br />confidential. Private data is information that generally cannot be given to ':it public but can be given to the subject of i�c data.
<br />Confidenrial data is informarion that generally cannot be given to either the public or the subject of the data.
<br />The City of Roseville is collecting the information to deteniliue qualificarions to serve on a Citizen Advisory Conunissioll.
<br />You are not legally requu�ed to provide this information. However, if you do not supply the informatioil, you ��rs not sei�ve oiZ
<br />a Cirizen Advisory Conmussion.
<br />Other persons or enrities authorized by law to receive tlus i��foz-z��atioiz are City Council members, staff, residents of Roseville
<br />and interested others.
<br />I understand that all information provided in ihi� application, except my telephone numbers, fax number and
<br />email address, lnay be distributed by tl�.e City to the ��'-1,1 �� including, but not limited to, being posted on the
<br />City of Roseville website. I agree to waive any and all clai�lls under the Minnesota Goveinlnent Data
<br />Practices Act, or any other applicable state and federal law, that in any way related to the disseminationto the
<br />public of infoi7i�atioza contained ii i tlus applicationthat would be classified as pi-ivate under such laws. I
<br />�ri���r�: iti�i i.� �l �,d I may �o��±ac± t?ze �-�s���zsi�le autl��rit�,� for +?Ae City of �? �sP��z?le if I have �nY� questions
<br />regarding the public or private nature of the infoi711atio1l provided.
<br />I understand that the City will not publish my phone or fax l�uinbers or em.a�l address without m�' autlaoi-ization
<br />and do hereby allow the City to �ublish (check all tl�at apply).
<br />� I �t�:� ��� telephone number
<br />work telephone x��.�u�ber
<br />�home einail address
<br />work email address
<br />r, +, y�; �:
<br />�I f��1' J L F �F� �� �� ������� yJ
<br />� 5ir��iNl��r� a��}�P�a]i�tu7! Date ofApplication
<br />8r,yyx�,�rn4,v.1 f;mYr�irir• n +,� � ?
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