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83/04/04 YV�� 1�tOfi FAX 85161398281 R�S�V�LL,� PROP�RTIES ��a3 The City of Roseville is collecting the information to determine qualificarions to serve on a Citizen Ad�isory Commission, You are not legally required to provide this information. However, if you do not supply the information, you may not serve on a Citizen Advisory Commissioa Other persons or entities authorized by law to receive this information are Cib� Council members, stai� residents of Roseville, and interested others. I understand that all i�formation provided in 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, baing posted on the C�r of Roseville website, T agree to waive any and all claims under the Minnesota Government Data Practices Act, or any other applicable state �d 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 C�ty of Roseville if I have any questions regarding the public or private nature of the information provided, understand that the City will not publish my phone ar fax numbers or ema� address without my authorization and do hereby allow the Cit�r to publish (check � that apply). _ home telephone number _ email address — work telephone number I understandthat I may be ��: �rro� �� �� 1�3 $�3�64 �dit�t� �ig�tn� by the C�t�r Council that may be aud.i.o or videota�ed. � �.�o�fi Date of Application