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�?�'hal « rri i�r r�t��ti ri F l�ac r����F fl� I��1"� � U�IIlIh�iS��It11�L {J112ir111 L['E'.'�l ;35k f� wct �' — -- <br />-j ��.rY �� • � � _�'+f � �� � ��� .� �1 � ��r����f�7hd� ��lY' { � <br />OtherComments: (Irrclirde�t,7�!i;��;�5s;-ilzfornzatiortyozrwauldliketl�aeCityCptaticiltoconsideror <br />tlxqt �oic feel is relevant to the appointment you are seeking. �t'�r may also attach ottzel' :�; t; r� ;��tiri �� �r'; <br />would Iike the Cotsncil to consider.) <br />Tennessen Warning - Some or ail the infart�atio�3 that you are asked to provide is classified by State law as eitl�er private or <br />confidential. Private data is infonnation that generally cannot be given to the public but can be given to t11e subject of the data. <br />Confidential data is info�nnatian that generally cannot be given to either the pub3ic or the subject of the data. <br />The City of Roseville is collecting the inionnation to detemiine qualifications to serve on a Citizen Advisory Commission. <br />You are not legally required to provide this information. However, if you do not supply the information, you may not serve on <br />a Citizen Advisory Commission. <br />Other persons or entities authorized by law to receive this infonrkatioi► are City Council inembers, staff, resi[lents of Rqsevi] le <br />and interested others. <br />� understand that all information provided in this application, except n�y telephone numbers, fax number and <br />�mail address, may be distributed by the City to the public including, but not limited to, being posted on the <br />...�ity of Roseville website.. ����c� tb waive.any and �11:�laims under the Mi;ruiesota.�����. t �=_m�� � Data. <br />Practices Act, or any othei` applicable state and federa� �aw; that in any way relatec� �� the dissemination to the <br />public of information contained in this application that would be classified as private under such laws. 1 <br />understand that 1 rnay contact the responsible authority for the City of Roseville if I have any questions <br />regarding the public or private nature of !he in�oz�nat3on provided. <br />I understand thatthe City will not publish my phone or fax numbers or emaiL address without my authorization <br />and do hereby allow The City to r�u�:;�:: (check all tfz�t apply) <br />'�! hon�e telephone number <br />t� woric telephone number <br />.,,_hanle e»ail address <br />� <br />_ •'�'�4 � �:'n l`I I1.7'., :I{::1�48�i� �. <br />• a� 4 �/ � <br />.��.�.. <br />r �ig;�il��r�, :.ai' , j;��: <br />� '� - ���f - <br />Date of:�����fi,�,�i-;�;� <br />