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l Nc.v. 16. 2012 8: 19AM No 1767 P 1 <br /> ✓▪ ie ` ` <br /> l e r N,// APPLICATION FOR REAPPOINTMENT TO CITY <br /> APPLICA <br /> City of ADVISORY BOARDICOMMISSION <br /> ,j,,c)... <br /> Elk: ........-, <br /> River Reappointment to: E D A <br /> 13065 Orono 1'acsc•y <br /> 763.635.1000 <br /> APPLICANT INFORMATION <br /> Name: D l4/1 / V E 17 City of Residence: , F L K <br /> Occupation: .5 .,P PL y Cit04/N AlG R.- Employer: <br /> 'S 1.L.5 Fio-e4 d <br /> Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br /> board/commission for which you are seeking reappointment.. <br /> • /L <br /> — , ' , ,i. '_- , as_ A •I fOM ��'J ` .� ., i �'-' 9 <br /> 0144 1,14.4-4.:i-D.c•5 j <br /> Relevant Experience:Please describe your a ational, professional,civic, or community <br /> participation,which ma be relevant in serving on this boats/commission. . <br /> IZ �. b ► A 8 t' A t..�_-0 . - <br /> c <br /> Attendance: Are your aware of the importance of regular meeting attendance including the time <br /> commitment involved in preparing for meetings, and do you feel you have the time available to be <br /> an active participant?76,Yes ❑ No . ' ' <br /> Comments: - <br /> Conflict of Interest is defined as the participation in any activity,recommended action, or decision <br /> from which the individual has or could have the potential to receive personal gain,whether it be <br /> direct or indirect. (See attached "Conflict of Interest" Ordinance) <br /> In accordance with this definition, do you have any legal or equitable interest in any business, <br /> however organized,which could be construed as a conflict of interest? ❑ Yes t5 No <br /> If yes,provide details on a sepapte piece of paper. <br /> . -- 1 l /16 l.2o 9- <br /> Applicant Signature Date <br /> Applications will be kept on file for one year;after that time, a new application must be filed. <br /> OFFICE USE ONLY <br /> Council Meeting Date: <br /> ❑ Reappointed <br /> Term Expires: <br /> 0 Not Reappointed <br />