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13065 U,ono Parkway <br />763.635.1000 <br />APPLICAT�OM FOR REAPPOINTMENT TO CITY J/` <br />ADVISORY BOARDICOMMISEION <br />Reappointment to: k� C <br />:�).Ka�i oC d I <br />APPLICANT INFORMATION `� <br />Name: ��S City of Residence: N 6 <br />Occupation:'' Employer: <br />Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br />board/con4mission for which you are s e reappo:lntmeat. <br />1 sj QrS e�'rS.e <br />Relevant Experience: Please describe your educational, professional, civic, or community <br />participation, which may be rele`rant in serer 01R this bo d/co Sion. <br />�f El�S <br />Attendance: Are your aware of the importance of regular meeting attendance including the time <br />commitment involve in preparing 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 interesta y business, <br />however organized, which could be construed as a conflict of interest? 0 Yes ANo <br />I yes provide details on a se aratepiece of 12al2er. <br />I1(VC3 <br />Applicant Signature Date <br />Application wX 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 />LI Not Reappointed <br />