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APPLICATION FOR REAPPOINTMENT TO CITY <br /> ADVISORY BOARD/COM MISSION <br /> Reappointment to: <br /> 1306SOtono:Packivay;::ritr?::•; `.. <br /> 763.635�100D...i:':ii��: .::.ar:.... <br /> APPLICANT INFORMATION <br /> Name: SCE City of Residence: <br /> Occupation: c Employer: <br /> �c�xr ' <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 /> t f <br /> c4cL a_e__Cu <br /> Relevant Experience: Please describe your educational,professional, civic, or community <br /> participation,which may be relevant in serving on this board/commission. <br /> Attendance:Are your Cware of the importance of regular meeting attendance including the time <br /> commitment involved ' preparing for meetings,and do you feel you have the time available to be <br /> an active participant? Yes EI 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? D Yes No <br /> If yes,p vide details on a se rte pjece of a er. f <br /> h,117 ` <br /> pp cant Signature Date <br /> Applications will be kep tle for one year,after that time,a new application must be fzled. <br /> OFFICE USE ONLY <br /> Council Meeting Date: <br /> Reappointed <br /> Term Expires: <br /> Not Reappointed <br />