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�r7�;rt i� ����ar ��i�'�� Of #h� roie �f [I�iS C'.ommi5Si0���1i�l�elfe�+`'f'ASk. k'r�»ct". <br />�� �r . �•r�:~ �v{i+.�� i-�'• � �?' �-r y�f <br />- '--' � '� <br />r •� i�..�• r��„�. ' ' i .�_. •„ •• i �.. r <br />��iF4i' � QiMit���f,4i; ��l IL`� �i' {: f.'lJ�': ;:� �. ... :�2� •:. . , i� _r'1 � � r� i 't'r12i_�� : � �.1' _. . . i f'�� rlii. a i � �. .:�'l�:ti_i.t'1' f'u <br />r��rr �r,�, �:? �.� �#?�2?YJrFJ f{3 �P �}fJJ4��YJ���f .�f�� Cf�'£ .5���iF7�. Yf1i'1 i�it��' [h�.Yfk �tdd4C'r2 CM�G4�T �#1�fE�'lfJ�S.�IfJd2 <br />�+ �#�=C� ,'xC ��'�+' �-i�L�ac'.��+� ��F��.. <br />� ��f��r � <br />- -- {if . _.:r_�f? �'/ L.'}�`:f.''�'Y��1.'�{ -- — -- <br />Tennessen Warning - Some or all the informarionthat you are asked to provide is classified by State law as either private or <br />confidenrial. Private data is informarion That generally cannot be given to the public but can be given to the subj ect of the data <br />Ca�idenuai data is 'u-sf'�,nnatio� that ge;�rally cannot be gi�rez7 to either il�e gu€iiic or i1�e su�iject of tl�e data. <br />The City of Roseville is collecringthe informarionto determine qualificarions to serve on a Cirizen Advisory Commission. <br />You are not legally required to provide this information. However, if you do not supply the information, you ma�' not serve on <br />a CitizenAdvisory Co�iuussio� <br />Other persons or enriries authorizedby law to receive this informarion are City Councilmembers, staff, residents of Roseville <br />and interested others. <br />r understandthat all infozmation providedin this application, exceptmy telephonenumbers, fax numberand <br />�rr��1 address, may he ;�� }�V��� by the City to �e public i;:�] � �rli��, ;�u� not 1i���ited to, being posted on the <br />City of Roseville cvebsite. I agree to waive any and all claims under the Minnesota Govemment Data <br />Practices Act, or any other applicable state and federal law,1�� �z ��y ��Qy r�.lated to the disszmzn�o�z to t�'�e <br />public of information contained in this applicationthat would be classified as private under such laws. I <br />����wi �LW��I that I may contact �� respor�sibx� ��'�cr�ty for the �'� �_, �f ��t��t �.� � if I have any questions <br />xe�ar��g ��e public �r N� i k��l�-�atare of u�;�,��s�na �on provided. <br />I understand that the City will not publish my phone or fax numbers or email address without my authorization <br />and do h.����� a11:,Y�° � e City to publish (c�eck �1 that apply). <br />�°home telephone number <br />w o r k telephone number <br />� nome emaa�. address <br />work em�1 address <br />- -� � � <br />_ ��� #f�', �,� — — <br />���n� rr��i�.Applicant <br />:,�,..+-,�..r,fcu�i . <br />�� � � <br />� <br />. <br />, <br />- - ���� �� -- <br />Date 6f Application <br />