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Tennessen Warning - Some or all the information that you are aslced to provide is classified by State law as either private <br />or confidential. Private data is information that generally cannot be given to the public but can be given to the subject of <br />the data. Confidential data is information that generally cannot be given to either the public or the subject of the data. <br />The 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 you do not supply the information, you may not serve <br />on a Citizen Advisory Commission. <br />Other persons or entities authorized by law to receive this information are City Council members, staff, residents of <br />Roseville, and interested others. <br />I understand that all information provided in this application, except my telephone numbers, fax number <br />and email address, may be distributed by the City to the public including, but not limited to, being posted <br />on the City of Roseville website. I agree to waive any and all claims under the Minnesota Government <br />Data Practices Act, or any other applicable state and federal law, that in any way related to the <br />disseminationto the public of information contained in this application that would be classified as private <br />under such laws. I understand that I may contact the responsible authority for the City of Roseville if I <br />have any questions 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 ernail address without my <br />authorization and do hereby allow the City to publish (check all that apply). <br />x_ home telephone number <br />�c email address <br />x_ work telephone number <br />I understand that I may be invited to an interview by the City Council that may be audio or videotaped. <br />Richard W.Jacobson <br />Signature of Applicant <br />�p��d: �� <br />�4 �+* k �.d �.�a� <br />..�.. �+�.yw <br />o� ��„��iias��r�t <br />R,-r, �,�-� ...�r <br />r..�.. <br />� <br />1/15/95 <br />Date of Application <br />