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6.3 EDSR 01-17-2017
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6.3 EDSR 01-17-2017
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1/13/2017 1:44:28 PM
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City Government
type
EDSR
date
1/17/2017
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TENNESSEN WARNING <br />APPLICATION FOR APPOINTMENT TO CITY <br />BOARD OR COMMISSION <br />In connection with your application for appointment to a board or commission the ("ity has askcd <br />that you provide it with information about yourself which is classified as either privah, or coqfidenfial <br />by the Minnesota Govcminctit Data Practices Act (MS 13.04). Accordingly, the ("Ity is required to <br />inform you of the following: <br />1. Residential address, telephone number, and email address are private. Once appointed to a public <br />body, the data becornes, public. <br />2. 'rhc private or confidential information requested includes the follouing: addilional (,-onlaa <br />Okmalion on lice sioplovenial applie'ation proi)iderl ira orderfivsIql <br />.1'm reach ,you. <br />3. The purpose andintendcd use of the information requested is:.,/oY- Cily Colmod audstqff' n,',i4env and <br />prow s.r.your applicalion, I Fle mill also need the iqlbriveilion iXjoll are appoinled in orderfi)r�,yolv loperlr my in <br />jour role as a boarelviembe,rlcofl;i7il's.rI'Olier. <br />4. You arc not required to supply the requested information. <br />5. The known consequences of refusing to supply the requested information is: delqy in nolaffi" g joll <br />andsendiii <br />1.9 <br />6. The following persons and entities are authorizcd by law to receive the information if provided: <br />(.ily Council and,u -Iqll' )Vhose ivork- asslgnmenIs rep /cairn " (icCeSS. <br />The undersigned, by signing this notice, acknowledges that he/she has read and <br />understands the contents of this notice. <br />d101-3 <br />Datcl <br />Signature of Applicant <br />Print Name <br />
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