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APPENDIX B <br /> <br /> Open Appointments Application for <br /> Dakota County Citizen Advisory Committees/Commissions/Boards <br /> <br />_~1; ApPlicant Information <br /> <br />Applicant Name: <br /> <br />Last Name <br /> <br />First Name M.I. <br /> <br />Mr. Q Mrs. <br /> <br />Home Address: <br /> <br />Ms. <br /> <br />Street <br /> <br />MN <br /> <br />Commissioner District: <br />Telephone: <br /> <br />city <br /> <br /> State Zip County of Residence <br /> <br />(Leave blank if you do not know the number of your commissioner district.) <br /> <br /> Home <br /> <br />[Part 2:?Committee Selection I <br /> <br /> Indicate below the name of the committee(s) for which you are seeking <br /> <br />preference (1 being your first choice). <br /> [~ Child Abuse Prevention Council <br /> <br /> [~ Child Care Advisory Committee <br /> <br /> [~ Communib/Corrections Advisory Board <br /> <br /> [~ Extension Committee <br /> <br /> [~ Housing & Redevelopment Authority Board <br /> <br /> [~ Human Services Advisory Committee <br /> <br /> Q Library Board <br /> <br /> [~ Noxious Weed Control Program Appeal Committee <br /> <br />IPart 3: Your Rights as a Subject of Data/Applicant Declaration <br /> <br />Business <br /> <br /> appointment. If more than one, number them according to <br /> <br />Q Parks and Recreation Advisory Committee <br /> <br />Q Planning Commission <br /> <br /> Shoreland Zoning Board of Adjustment <br /> <br />Q Solid Waste Management Advisory Committee <br /> <br />[~ Special Board of Equalization <br /> <br />Q Workforce Council <br /> <br /> Other: <br /> <br />Minnesota Statutes Ch. 13 on data pdvacy requires that you be informed that the following information which you are asked to provide <br />in this application is considered pdvate data: home telephone number, business/financial interest, status as recipient of human <br />services. This means it is available only to you and county officials who have a bona fide need for it. This data will be used to 1) <br />contact you regarding your applic3tion or 2) determine your eligibility for appointment. Furnishing your home telephone number, <br />business/financial interest information, and status as recipient of human services is voluntary. Failure to provide the information <br />requested in Parts 5-10 of this application may result in denial of eligibility. All information you supply on this application, with the <br />exception of that which is private data as indicated above, will become public if you are appointed to serve on a Dakota Coum'y citizen <br />advisory committee. <br /> <br />ereby declare that I have read the statement 'Your dghts as a subject of data' regarding the Minnesota Government Data Practices <br /> (Minnesota Statutes Ch. 13). <br /> <br />Signature of Applicant <br />Page I <br /> <br />Date <br /> <br />B - 1 <br /> <br />Please continue... <br /> <br /> <br />