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HotiF h�� 3'tE«r ��[etiY 0� th� [�GI� r�l' 1 q1 i k['��nl G�li.k� ia7n r I i.i r��;t:[I �lnc�c: � i i u r E i e.�� t� e���'x -- <br />1 -� � — - <br />Y�� I'll_ — n . rr � � �t � I--• r • - ---�. • " t ti � • ,� _ �— .— ' S ir4 � � F <br />� ►��-2 � � � +[ �.�. i �^ � a ►�a 'n i ,S� � D-.L r S � � � ��� rJ'ti �r,.- �u '��.,c� � ���� j+�r �-r•'��;�� <br />---�-- =• - --.�:_. � i.__. �__� I i �_..— <br />{.+r � r G� .ti <br />�rF �ur.l� �i <br />�-t.{ �.O N., vn i� 3 � ff n �+1 }" r i_- tir-� Y_ �} _.: � � �; � 1+�ti5 r�� <br />� r <br />5� �.., ,�. � �� .'� { :--o.. � ��.i 5'� i• , "' ' � �� '� � � ;�.�'� �_ � r—�'.�`�?t.� � F _ �-y � �, � +� •t � 5 , d-� <br />-� • � 4 . i ._GJ � ` � Z..�-�i <br />'� `r �. ^ L � � j �. r'� �-�J' � .5 � �r+� �-Y • r''' i �5 �Y {. � � - L f} } i _ 4 � U ' � • i _ �_ �t�'L ,. r � L. r!�, �ir ,'�' a� I "`�'� <br />{�th�.r �:�n� rr��» �s: ���'ai��ia��� �x�1'.��r���r rra���x������rr }+�u �+��� �iJ� k�r� ��y �'�ux,r��� r�x �� r�r � :��=�=.� <br />��ir��}��}'�ei �s rc����� �r� ��- ��p��a�ar��+�r,i_ �'� rrzr�}��r�.�v ar��e�+ �ifi�rmir����ia�.� w� rur�„!r� frktf r��t� <br />C.'�z�r�d �� cv��,€�r���.� <br />� � , . - -- <br />'1'� r ���, � • ' ' _ ,�_�r�3 � f 4.�.._.._ ._ _ � r.fr:T� '- �;{••� ...._. � '.. . ' - <br />� � • . <br />I' {] O7 k I F� }' {,�—.. ��"� l <br />Tennessen Warning - Some or all �at• inforination that 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 the public but can be given to tl�e subject of tl�e data. <br />Confidenrial data is information that generally cannot be given to either the public or the subject of the data. <br />The City of Roseville is collecring #he infoimation to determine qualifications to seive on a Cirizen Advisory Conunission. <br />You are not legally required to provide this infoinlation. However, if you do not supply the information, you may not sexve on <br />a Cirizen Advisory Comnussion. <br />Other persons or enrities authorized by law to receive this infornlation are City Council members, staff, residents of Roseville <br />and interested others. <br />I tu�derstaz�d that all infoi�ation provided in this application, except my telephone nuinbers, fax nunlber and <br />email address, m,:�� be distributed by the City to the public including, but not limited to, being posted oi1 the <br />City of Roseville website. I agree to waive any and all clain�s under the Minnesota Goveinlnent Data <br />Practices Act, or any other applicable st�te �� :�1 federal law: that ii� any way related to the dissen�iilation to tl�e <br />public of infoz��atio�� contained i�l il ii� application that would be classified as private under such laws. I <br />understandthat I may contact .l i� responsible authoi-ity for the City of Roseville if I have any questions <br />regarding the public or private nature of the infoiznatioll provided. <br />I understand that tl i� City will not publish my phone or fax ilumbers or email address without 111y authorization <br />and do hereby allow the City to publish (check all tl�at apply). <br />,� � f':I }I ��C �� �i�7� Il]L:L' I I LI�S IU�C <br />� x��� frk ��I�s]7�aC �Y�i�y�ber <br />�� T�F���� ��s�a.i[add��5s <br />kv��ic �rr,aiJ �.ldress <br />� � ' � �f - � <br />� ". "���. - ��r�-Y �..r �w � ; . . <br />_— F �7���WCLLLL �4a 1L/I�IILLY�L <br />�n��ainA+��c+u' •{I�+� nniu• i�;': � <br />':'-�. � �- � �� � <br />r};LLL' l}� ���j�C�J�l�a�7 <br />J <br />