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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 anv business, <br /> however organized,which could be construed as a conflict of interest? es ✓ No <br /> If yes,provide details on a sel2arate pigice of paper. <br /> Jill Larson-Vito %W ­V4%1, � ° •�m,C.U5 1/28/14 <br /> Applicant Signature Date <br /> Questions may be directed to the Administration Department at 763.635.1000. <br /> OFFICE USE ONLY <br /> ® New Applicant ® Reappointment <br /> Council Meeting Date: <br /> ® Appointed to: <br /> Term Expires: <br /> Not Appointed <br />