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- ��-� --��---�-�� --------- -��••- <br />�' f�4� iw �+�Fur �a�w ��f �hr rnle rrf fhis Comm�ionl�Cam mitiu���sk Force'k . -- <br />� -.� t�i.�h' � �#' � A.i �r �`��,r�M I �� f ��5 �i�tir ti �� _�� � � � � <br />�...� C?'��," ��a�� L.,��� L.�'� • i► •���'���; =� <br />,� ��t+s�� � � t3't�-�-`� ����P '� -�-r� � r� � z�j�! �� <br />� i T�-ti C� i � ��i� ���- �1�4.��+ � � �� � . `-r�-�� �� 1..�� � �r.� <br />1�� _. L��� . M�t J4 I�l _ti �_� xi �� i ��1�� l�ti� C'��� ! 5�ti � <br />. � r� ��i��� � ��� r t�b."��� f��+� �'t+�-.�ti...� � .���.._.�����,�-+ ? <br />���her �'om �er�ig; ��rr�fp� ��'�wrl�ser i�rj�ana�inM � sw;d� iike f�e �'zt}� �'� i� r� �,x�esr�%�r �� � +� � � <br />r},�r yr����P'f �F �:F�}'rr� !{� d� r,�p �rr�rMeru �rr�r �rr� ae,e�'�. Yor� moy a�so �r�c�h o�k�r ���ri�'i �r� '����� <br />w•r �ir�r� Frk.° Fkr C�ri 4rsa� !ri r•rr�ir�rh:• � <br />- ---•---.._._.. • — --`'a�'�- <br />'E'ennessen Warning - Some or all the information 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 the subject of the data. <br />Confidential data is information that eenerally cannot be given In either the r���blic; or the sub;ert of the data. <br />�I-he City of Roseville is collecting the information to determine qualifications to serve on a Citizen Advisory Commission. <br />You are not legally required to provide this information. However, if yau do not supply the information, you may not serve on <br />a Citizen Advisory Commission. <br />Oth�r persons or entities authorized by law to receive this information are City Council members, staff, residents of Roseville <br />and interested others. <br />[ understand that all information provided in this application, except my telephone numbers, fax number and <br />e�naiE address, may be distributed by the City to the public including but not limitedtq being posted on the <br />City of Roseville website. I agree to waive any and all claims under the Minnesota Government Data <br />Practices Act, or any other applicable state and federal law, that in any way related to the dissemination to the <br />public of information contained in this application that would be classified as private under such laws. I <br />understand that 1 may contact the responsible authority for the City of Roseville if I have any questions <br />regarding the public or private nature of the information provided. <br />I understand that the City will not publish my phone or fax numbers or email address without my authorization <br />and do hereby allow the City to publish (checic all that apply). <br />home telephone number <br />—worlc telephone number <br />... home email address <br />work email address <br />� � � <br />� � -�� a� <br />�i y r,�pp r.�r�t , Date of Application <br />r�:;, ..; .. qsa�� r ; <br />d <br />