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}'�'Li:�� «u��ur ►��{tiv o� �9�e r��lc ��f tl�e �'U�nmuniC� ��ItiIUL.LCL� ��ttrin � f�'LJRIJJ1Lt�CL`'� <br />I � � <br />�� ���,.,.� � . ��+� ��`�'�- �.��t�� ��� `��' .� � ����rr ��� <br />. f�- �r,e �.1� .� . �� � �� F Z�7 ���. _ .�.'!r*�`s�� _ �� � — — <br />� 'r+ �T1�}'*tS �af �' x,� � t � � . � ��. � �.f.4�� . <br />r.�.�►p �.,� � I � �� �� � �� , � , ,� �� <br />. ���•� � ��'�!��� � �f71r� i • � � �� � L 1,�'4'"� ��`-4� � ��� � �� � _ �' "t� - <br />�1������ � � � �� �� �� _ ,�` � � � ���� �-� �t � .�- �'��' — <br />-��� - � <br />� .�, ��� ���� r������- . � ��� ��t¢-���� <br />�� ����r�a`�`���x • �" �-� — <br />Other Coin�ents: (Include any furtlzer ilzfol�r�xatio� you would like the City Council ��� consider or <br />t77�at you. feel is relevant to i7ie ap,�oin�tla��er�t you are seekin��. You 1�zc�y c�lso attcacl2 other rr�.r�t,errr�ls you. <br />-°t?:! iike the Cauncil t� � ,�����'��.r ' _ <br />r - <br />Tennessen Warning - Some or all the iaformatinn that you are asked to provide is classified by Slate law as either private or <br />co�identia�. Private data is infomlatioa tl�t generally cannot be glven to the public but can be given to the subject of the data. <br />Confidential data is i�forn��ti�n that generally cannot be given to either the public or the subject of the data. <br />The Ciry of Rosevil�e is collecting the inforn�aiion to detern�ine qualificatious to serve on a Citizen Advisory Con�n�ission. <br />You arc not legally requued to : i•:'• �`: t�vs inforn�atian. However, if you do not supply the information, you �ua� not serve on <br />a Citizen Advisory Co���issian. <br />Other persons or entities authorized by law to receive this information are Ciry Council members, staff, residents of Raseville <br />and interested others. � "' <br />I understand tl�at a11 i��forta�a�o�1 provided in :1� : application, except my telephone nu�lbe��-s, fax i��ul�be� a�1d <br />email address, nzay be di�t�z�uted by the City to the public including, but ilot lun.ited to, being posted on the <br />City of Roseville wel�site. I��_= to waive any and a11 c1a��ns under tl�e �Mi�lesoia Gove��unent Data <br />Practices Act, or any other applicable state �;; •� i fcderal 1aw, that � any way related to :-.�� dissemination to the <br />public of i�1fo���aa�an contained ir1 ��I�is ap��lzcai�on i: i�� would be classi�ied as private ir:,l�.: i such 1aws. I <br />understand that I 1�7ay cont'act the respo�zsible �utlzo�-ity �or tlle City of Roseville if I have :��;;: questions <br />regarding the public or private nature of the infamlati��� provided. <br />I unde�stand that the City wi11 iaot publish my phone or fax 1�uinUers or clliail address without i�iy atYlhoriza�ion <br />a11d do hereby a11ow i17e City to 1�ubl�ish (check a11 that apply). <br />� <br />;� ;�..1���_ ��iti;1- �:i7L�..L.:�7°:ti��� �`� �5 � �� i. '..!� r:it���i.. � �:�::I��.: � <br />���� � � <br />� i � �at�ire o£1�ppjicant <br />�a�a��� ,�� <br />� :+f .. ..,-- <br />�"� �t'..I�•II� •'.i �;:'`�'��tii 5'� I�: t'il� I''. I''.�'.�� �. <br />- - .�n, o� -- <br />Date of A�1�licatian <br />� <br />