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12-29-03;t3�47 ;VTI SECURITY �4�� *�� }d¢$ � �� Tennessen Warning - Some or all the information that you are asked to provide is classified by State law as either private or confidential. Private data is information that generally cannot be given to the public but can be given to the subject of the data. Confidential data is inFprniation that generally cannot be given to either the public or the subject of the data. The City of Roseville is collecting the infonnation to deterniine qualifications to serve on a Citizen Advisory Coinmission. You are not legally required to provide this inforniation. However, i f yot� do not supply the information, you may not serve on a Citizen Advisory Commission. Other persons or entities authorized by la�v to receive this information are City Council members, staff, residents of Roseville, and interested others. 1 understand that all inforn�ation provided 'm this application, except my telephone numbers, fax number and email address, may be distributed by the City to the public including, but not limited to, being posted on the City of Roseville website. I agree to waive any and all claims under the Minnesota Government Data Practices Act, or any other applicable state and federal law, that in any way related to the dissemination to the public of information 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 regarding the public or private nature of the information provided. 1 understand that the City will not publish my phone or fax numbers or email address without my authorization and do hereby allow the City to publish (checic all that apply). _ home telephone number _ j� einail address — worlc telephone number I understand that I may be invited to an interview by the City Council that may be audio or videotaped. � i�n�[�i rc �� , ��I ic�nt 4r�� i�4x � ��—�� Date of Application