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'4T�'h at as ��ai r��ifiw �i th e t�le �f this ���3jrtti5�i��}C'om rtil�te`fa� k�'t�r¢e? _ . ..— <br />- r� � - -�-- � ��� .. — , . � <br />. �_. i,j1���=��.£�.. �.�'��� � �� T . . <br />� _4 ���� rk 4 { �t � �;� � � �T� � h,:��� � �� ,� <br />� .� f . -._ -� . <br />�.S y {�y <br />�'�'T f• ��•�'�—� ]--+��K'�—` � F�' , �"�` 4 . � � , _ r�� C�`� � � �l � } <br />_ . ' � r �1. rf � � ' � . �r `�'il�i� . 4� - - <br />- • ,�4'y�`JI,�� ! �� �j ' - - '- '- ' y - <br />Other Comments: (Include any further informatio�a you would like the City Cour�cil to corzsider or <br />that you feel is relevm�t to ;�:' appointment you are seel�i�zg. You 1�zay also attaclz othev �nateric�ls you <br />wouZd like the Council to co�zsider. <br />,� <br />�,.� , � �� c� — �f ��; ������ ���4r`��s� , �,�� ,, i � _ ��� i j <br />.� _. . �-'--- � �- � - _--- �� <br />Tennessen Warning - Same or all t11e i�forn7ation �ia l you are asked to provide is classified by State law as either private or <br />coniidential. Private data is information that generally ca�uzot be given lo the public but can be given to d�e subject of I� data. <br />Confidential data is u�foi�nation that gezzerally canraot be given to either the public or t�ze subj ect of the data. <br />The City of Roseville is collecting t1�e infomation to detell��ine qualificatioi�.s to serve on a Citize� Advisory Conunission. <br />You are not legally required to provide this u�fo�xnatio�. However, if you do uot supply the information, you may not sene on <br />a Citizen Advisory Con2nvssion. <br />Otl�er persons or eiltities authorized by law to receive t��s infoirnation are Ciry Couucil n�e�i�bers, staff, residents of Roseville <br />and interested others. <br />I understand tl7at all iiaf`oi7nation provided in tlus application, except n�y telephone ����be�-s, fax r�a�;: ���r a��d <br />enlail adciiess, may be distributed by the City to the public including, but not l�nit�d to, �ei��g posted on t��e <br />City of Roseville v,rebsite. I ag� ee to waive any anc� all claims under the Minnesota Govez��.ne�Zt Data <br />Practices Act, or any other applicable state and federal law, tl-�at in any way related to the dissemination to 1] i� <br />public of infoinzafiion contained i:� tlus application that would be classified as private under such laws. I <br />unde�-,�tand that I n�ay contact the responsible authority for the City of Roseville if I have any questions <br />regarding the public or private nature of the uifoi�natior� provided. <br />I undexstai�d that t%e City will not publish my phone or fax ��tainbers or email address without my authorization <br />and do hereby allow ih�� City to publish (check all that apply). <br />��ome telephone ntu�7ber <br />�work telephone nwl�ber <br />1�t7�7�;� email address <br />_ w�,:� t� ;7:ii1 .i,'tl°Lfk.'� r , <br />,� <br />� � . <br />__ _ f ���._ <br />�; ��ti1�l'� r�E;p li ut�il l <br />+;•,� •rr�y�u- c{r�L�: <br />� r. � <br />_ t� ���� <br />Date of A}�p!i�ation <br />� <br />c <br />