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`, 'I REAPPOINTMENT T IT <br /> City of ISORY BOARD/COMMISSIO <br /> �.: JAN 2013 <br /> ® ` p—ap?p�oin ent to: I (.tee IV-vitti eoyy�gl- -; <br /> 13065{Mono 11 kwv y Viz\ ,,,a,A..�u� °' <br /> 763.635.1000 ''� <br /> APPLICANT INFORMATION <br /> Name: I\A & CU \,�V"\ �/-s-V,-- City of Residence: i���►�+5 <br /> Occupation: X'1 S. 10--AJ-- '°F ' Employer: J 0 # ZZ , <br /> Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br /> boa d/commission for which you are seekin reappomn ment. <br /> Relevant Experience: Please describe your educational,professional, civic, or community <br /> participation,which may be relevant in serving on this board/commission. <br /> l`°1'� °'L'Q.;t� -- ���c�v�.y�e;�'� f�>t-�'`-�•. `t`c.� _C5`72,�`> <br /> Attendance:Are your aware of the importance of regular meeting attendance including the time <br /> commitment involved ' pzeparing for meetings, and do you feel you have the time available to be <br /> an active participant? 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 o <br /> If yes,provide details on a se arate piece of paper. <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 /> El Not Reappointed <br />