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APPLICATION I T T TO CITY <br /> City of ADVISORY BOARD/COMMISSIO <br /> Lk <br /> RiVe-T Reappointment to: <br /> 13065.6-0 Parkway <br /> 763.635.1000 <br /> APPLICANT INFORMATION <br /> Name: City of Residence: LIV- <br /> Occupation: MAWA<kewt Employer: ° <br /> Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br /> board/commission for which you arq seekin reappointment. <br /> I <br /> A uo <br /> R%ev peri c : Please esct ft4L&ational,professional, civic, or community <br /> participation,which may be relevant in set in on this board/commission. <br /> l <br /> - (st 9 ® e <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? es El 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 /> how Ayer organized,which could be construed as a conflict of interest? El Yes &No <br /> If y ,provide details opra separate niece of naner. <br /> a, w. <br /> e 0 <br /> Applicant Si tune 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 /> El Reappointed <br /> Term Expires: <br /> EI Not Reappointed <br />