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7'en nes5en Warning • Sorne or all the information that you arc asked to provide is classified by State law as eitha private or confidential. Private data is information that geacralty cunnol bc given to the public but ccur be given to the subject of the data. confidential � is information that geaerally cannot be given to eithcr tho public ar the suhject of the data. The City of Roseville is collectmg the information to determine qualifications to serve on a Citizen Advisory Commission. You are not legally reqvired to provide this infonr�ahon, However, if you do not supply the infornmtion, you may not scrvc un a Citizen Advisory Conunission. Qtlier persons or cntiGcs auehoriz�d by law to receive this information are City Council members, �e�'', n;siJcnts of Roseville. ancl interestedothers. I understand that all information provided in this application, except my telephone numbers, fax number and emai[ address, may be distributed by the City to the public including, but not limited to, being posted � the City of Roseville website. I agree to waive any and all claims under the Minnesota Govenuncnt Data Practices Act, or any other applicable slate and fedearal law, that in any way rclated to thc dissemination to the public of infortnation contained in this application that would be classified as private under such laws. I understand that I may contact the responsible authority for the City of Roseville if I have any questions regarciing the public or private nature of the information provided. I underst��nd that the City will not publish my phone or faY numbers or email address without my authori�ation and do hereby allow the City to publish (checic all that apply). — home telephone number —cmail address X worlc telephone number und�ra�lan�i tha� }� ��r�wi�� an in��it� �}' the City Council that mdw � a =0 �pt ��iQU4h�- r � � � � � �{+r�� of Applicant 4 Date of Application � L�ac�i: � aa�