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8��f�� 09;17 FAX 862 820 1694 NORTHCO REAL ESTATE SERV [�003 Tennessen Warning � Some or all the information that you are asked to provide is classifiedby State law as eitherprivate or confidential. Private data is info,ra�ation that generally cannot Ix given to the public but can be given to Q�p subj ect of dl� data. Confidential � is information that generallycannot be given to either the public or t�ic subj ect of the data. The ((�iy of Roseville is collecting the information to detemline qualifications to serve on a Citizen Ad�isoYy Commissioc�. You are �not legally required to provide this infonnation. However, if you do not supply the information, you my not serve on a Citizen Ad�isory Commission: OtEier persons or entities authorizedby law to receive this informationare City Council members, staff, residents of Roseville, and interested others. I understand tllat a I I infornlation provided in this application, except my telephone numbers, fax number and email address, may be distributed by the City to the public inclurairr�, but not limited to, being posted on the City of Roseville website. I agree to waive any and a I I claims under the Minnesota Govemment Data Practices � 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 infpzmation provided. I understar►d that the City will notpublish my phone or fax numbers or email address without my authorization and do hereby allow the City to publish (check a I I that apply). � home telephone number �email address w�arlt telephonenumber understand tllat I may be invited to an interview by the City Council that x�ay be audio or videotaped. � � � SignatureofApplicant ��{ FpU��,�, upda�d: � rz�roa