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13065 Orono Parkwvy <br />763.635.1000 <br />JAN 10 nv <br />APPLICATION FOR REAPPOINTMENT TO 0TV <br />ADVISORY BOARD/COMMISSION <br />Reappointment to: U T1 L I r I 0 �D fJl P71 3 51 a `'2 <br />APPLICANT INFORMATION <br />Name: ALJ—e A- [.L City of Residence: <br />Occupation: _//u, m L e i^ Employer: <br />Statement of Interest: Please state briefly why you are interested in continuing to serve on the <br />board/commission for which you are seekine reatn3ointment. <br />Relevant Experience: Please describe your educational, professional, civic, or community <br />paV pation, which mai be relevant in serving on this board/commission. <br />A _ n n 1 /i <br />Attendance: Are your aware of the importance of regular meeting attendance including the time <br />commitment involved in preparing for meetings, and do you feel you have the time available to be <br />an active participant? 99 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 /6 No <br />If yes, provide details on a separate piece of l2aper. <br />?O/7 <br />Applicant Signature Date <br />Applications will be kept on file for one year; after that time, anew application must be filed. <br />OFFICE USE ONLY <br />Council Meeting Date: <br />❑ Reappointed <br />Term Expires: _ <br />13 Not Reappointed <br />