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APPLICATION FOR REAPPOdNTMFN7 TO 077 <br /> ity of 1� ADVISORY BOARD/COMM SSION <br /> Cl� <br /> Ei <br /> t veT Reappointment to r�� � e tr.•sn 1 i ; <br /> 1306S 0m..11-kw y C "'' <br /> 763.635.1000 <br /> APPLICANT INFORMATION <br /> Name: City of Residence: <br /> Occupation- Employer: tic? J <br /> Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br /> board/commission fo hich you are seeking %appointment. <br /> __rr rr <br /> C-5 ce Cxa� .ss e�ceur6 <br /> Relevant Experience: Please describe your educational,professional, civic, or community <br /> par ' 'pati n, which may be relevant serving on this board/commis ion. ( <br /> C i k a Gt ✓ <br /> Attendance: are your aware of the importance of regular meeting attendance including the time <br /> commitment involved in oreparing 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 VrNo 7;*es, pr d �etail on a se crate 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 /> LI Reappointed <br /> Term Expires: <br /> ❑ Not Reappointed <br />