Application for Citizen Advisory Commission

Please check commission applying for*

Ethics Commission Grass Lake Water Management Organization Human Rights Commission Parks and Recreation Commission

Planning Commission Police Civil Service Commission Public Works, Environment and Transportation Commission Other

If other, please list name

Name:*

Address:*

City, State, Zip*

Work Experience

Education:

Civic and Volunteer Activities (Past and Present):

Please state your reasons for wanting to serve on the Commission/Committee/Task Force:

What is your view of the role of this Commission/ Committee/Task Force?

Any further information you would like the City Council to consider or that you feel is relevant to the appointment you are seeking.

I understand that all information provided in this application, except my telephone number, fax number and email address, may be distributed by the City to the public including, but not limited to, being posted on the City of Roseville website. I agree to waive any and all claims under the Minnesota Government Data Practices Act, or any other applicable state and federal law, that in any way related to the dissemination to the public of information contained in this application that would be classified as private under such laws. I understand that I may contact the responsible authority for the City of Roseville if I have any questions regarding the public or private nature of the information provided.*

Yes

I understand that the City will not publish my phone or fax numbers or email address without my authorization and do hereby allow the City to publish (check all that apply).

Home telephone number Work telephone number Other telephone number Home fax number

Work fax number Home email address Work email address

Daytime Phone

Evening Phone

Cell Phone

Home Phone (if different)

Work Phone (if different)

Home Fax

Work Fax

Home Email

Work Email

Student Application

No Yes

If yes, please list your grade

May we contact you using your work email or fax?*

Yes No

Tennessen Warning: Some or all of the information that you are asked to provide is classified by State law as either private or confidential. Private data is information that generally cannot be given to the public, but can be given to the subject of the data. Confidential data is information that generally cannot be given to either the public or the subject of the data.

The City of Roseville is collecting the information to determine qualifications to serve on a Citizen Advisory Commission. You are not legally required to provide this information. However, if you do not supply the information, you may not serve on a Citizen Advisory Commission.

Other persons or entities authorized by law to receive this information are City Council members, staff, residents of Roseville and interested others.

Any additional information may be emailed to info@ci.roseville.mn.us or delivered to Administration Department, City of Roseville, 2660 Civic Center Drive, Roseville, MN 55113 or faxed to 651-792-7030.

I have read and understand the statements on this form, and I hereby swear or affirm that the statements on this form are true. *

Yes