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13065 o-- Parkas, <br />7(Z 635.1(19111 <br />Ip PPUCA7MM FOR REAPPMNTMENT 70 CATV <br />ADVMORY RCARMC®MWSS�ON <br />Commission Rea plying for <br />First NameL\ <br />Last Name <br />•� <br />Address <br />City <br />State <br />Zip <br />Home Phone Cell Phone Email <br />Employer Occupation <br />t-,-) i-& e 5v N Clt /�AV� <br />Public Contact Information <br />The city maintains a directory of current board/commission members on the city's website. Once <br />appointed, state statute requires members to provide a telephone number, emnail address, or both where <br />the applicant can be reached. This is the contact information we will include in our online directory. <br />Please indicate which contact information you would like us to use: <br />❑ Home Phone Number `I Cell Phone Number ❑ Email Address <br />State briefly why you are interested in continuing to serve on the board/commission for which you are <br />seeking reappointment: <br />��, , <br />"J <br />t �<kAd`S 0,0 Vcx Lc -Q 4c:> `f LQ, Corp, M i55loly <br />f2G1 f 1t% 1l���c f,o �e DFeg04IA/Pi <br />Attendance <br />Are you aware of the importance of regular meeting attendance including the time commitment involved <br />in reparing for meetings, and do you feel you still have the time available to be an active participant? <br />W Yes ❑ No <br />Conflict of Interest is defined as the participation in any activity, recommended action, or decision from <br />which the individual has or could have the potential to receive personal gain, whether it be direct or <br />indirect. Do you have any legal or equitable interest in any business, however organized, which could be <br />construed as a conflict of interest? ❑ Yes /It No <br />If yes, explain on a separate sheet of paper. <br />Applicant Signature <br />Date <br />Board/Commission Application Page 1 of 1 <br />