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13065 Orono Parkway <br />763.635.] 000 <br />A'PFL HC A77 OKI FOR REAPPOINTMENT TO CITY <br />ADVO SOIRY BOARD/COMMISSION <br />Reappointment to: _—A eyi6- Co m M <br />3chC6( <br />i ca eve <br />APPLICANT INFORMATION <br />Name: K'% C V% VNI 1, rt 4 Gt V" City of Residence: &M3 -e kl <br />Occupation:Ti v i 7� eS t�� re r Employer: -7 - y k v t! -�; !;. <br />Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br />board/commission for which you are seeking reappointment.I , <br />gllIg <br />Relevant Experience: Please describe your educational, professional, civic, or community <br />participatiorn, which <br />am may be relevant in serving on this board/ commission. <br />v or et <br />r�i rye v�.�,_ l" ��rn�y„t.� stv�-- i�2 ►�"`�l+/ ..�_ <br />Attendance: Are your aware of the importance of regular meeting attendance including the time <br />commitment involved in p eparing for meetings, and do you feel you have the time available to be <br />an active participant? es ❑ 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 gaud, 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 aiy business, <br />however organized, which could be construed as a conflict of interest? ❑ Yes No <br />If yes, provide details on a s arate pjeLce of 12aper. <br />/, <br />Applicant Signature Dat <br />AppEcations wiU be kept on file for one year; after that time, a new application must be fled <br />OFFICE USE ONLY <br />Council Meeting Date: <br />❑ Reappointed <br />Term Expires: _ <br />❑ Not Reappointed <br />