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13065 0-- P -k—, <br />763.635.1(") <br />APPfioOCATMN FOR REQl''PMNTiMENT TO CMf <br />ADVMOfRY BOARD/COMR{]i ISSDON <br />Commission Reapplying for <br />i / d - 6 <br />First Nam <br />Last Name <br />L <br />/ <br />t-7� <br />Address <br />City <br />State <br />zip <br />-33 <br />Home Phone Cell Phone Email <br />Employer Occupation <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, email 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 />Q Home Phone Number ❑ Cell Phone Number UO 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 />�r <br />Attendance <br />Are you aware of the importance of regular meeting attendance including the time commitment involved <br />in preparing for meetings, and do you feel you still have the time available to be an active participant? <br />a 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 2( No <br />If yes, explain on a separate sheet of paper. <br />�i Irl <br />Date <br />Board/Commission Application Page I of 1 <br />AV57ant <br />re <br />�i Irl <br />Date <br />Board/Commission Application Page I of 1 <br />