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2. This application is for Roseville residents who are seeking reappointment on a commission.

   COMMISSIONERS MUST BE CURRENT ROSEVILLE RESIDENTS.

   In order to complete this application, you will need a valid email address. All items marked with a star (*) are required fields.

4. Contact Information
   Under state statute, commissioner's names, addresses and either a phone number or an electronic address where you can be reached are public information. All other personal information is private data and cannot be released to the public unless the commissioner gives permission for the city to release it. Information relating to a student representative is private data and will not be released.
6. First Name*
7. Last Name*
9. Address 1*
11. Address 2
13. City
14. State*
15. Zip Code*
17. Home or Cell Phone Number*
18. Email Address*
20. How many years have you been a Roseville resident?*
22. What commission would you like to reapply for?*
    -- Select One --FinanceHuman Rights, Inclusion and EngagementParks & RecreationPlanningPolice Civil ServicePublic Works, Environment & Transportation
24. Note
    There is no character limit for the fields below.
26. The city's commissions review specific areas of interest and provide advice to the city council. Please describe why you want to continue serving on the commission.*
28. Please describe any activities, specific skills or experiences you have that are beneficial on the advisory commission.*
30. As a commissioner, how do you contribute to the city's equity and inclusion initiatives?*
32. Please indicate any reasonable accommodation needed during commissioner interviews and onboarding.
34. Preferred method to be contacted
    City staff contact all applicants approximately four days before the interviews to confirm interview date, time and location. Please indicate your preferred way to be notified.
36. Preferred method to be contacted*
    -- Select One --EmailTelephoneMail
38. Please provide alternative phone number or email if different from above
42. Demographics

    The City of Roseville seeks to increase diversity on volunteer commissions; diversity in terms of: racial, economic, age, gender, geographic, sexual orientation, ownership, disability and education attainment. Your answers on this form help us determine the success of our efforts and are not used in determining appointments to boards and commissions. Your information is kept strictly confidential and when reported, will not identify any individual.

44. How do you identify your gender?*
    -- Select One --FemaleMaleTransgenderNon-binaryOtherChoose not to self-identify
46. Do you rent or own?*
    -- Select One --RentOwnChoose not to self-identify
48. Do you have a sensory, physical, or mental disability?*
    -- Select One --YesNoChoose not to self-identify
50. If yes, into which category does your disability fall? (Choose all that apply)*

    1. Mobility
    2. Sight
    3. Hearing
    4. Speech
    5. Developmental
    6. Other
    7. Choose not to self-identify
52. If "Other" please describe:
54. If "Other" please describe:
56. What category represents your age?*
    -- Select One --18 to 24 years25 to 39 years40 to 54 years55 to 64 years65+Choose not to self-identify
58. What was your total household income in the previous year before taxes?*
    -- Select One --Less than $25,000$25,000 to $49,000$50,000 to $74,000$75,000 to $124,000$125,000 to $199,000$200,000+Choose not to self-identify
60. What is your employment status? (Check all that apply)*

    1. Employed - Full Time
    2. Employed - Part Time
    3. Full time student
    4. Retired
    5. Unemployed
    6. Self-employed
    7. Homemaker
    8. Other
    9. Choose not to self-identify
62. If "Other" please describe:
64. What is the highest level of education you have completed?*
    -- Select One --Some high schoolHigh school or GEDSome technical schoolTechnical school graduateSome collegeCollege graduatePost graduateOtherChoose not to self-identify
66. If "Other", please describe:
68. What is your race/ethnicity? (Check all that apply)*

    1. American Indian/Alaska Native
    2. Asian
    3. Black/African American
    4. Hispanic or Latino origin
    5. Native Hawaiian or other Pacific Islander
    6. White/Caucasian
    7. Other race/ethnicity
    8. Choose not to self-identify
70. What tribe(s) are you affiliated with?
    -- Select One --Bois ForteFond du LacGrand PortageLeech LakeLower SouixMille LacsPrairie IslandRed LakeShakopeeUpper SouixWhite EarthOtherChoose not to sel-identify
72. If "Other" please describe:
74. If you selected "Asian", please choose:
    -- Select One --HmongCambodianVietnameseKarenAsian IndianBangladeshiChineseFillipinoIndonesianJapaneseKoreanLaoMalaysianPakistaniSri LankenTaiwaneseThaiBurmeseOtherChoose not to self-identify
76. If "Other", please describe:
78. If you selected "Black/African American", please choose:
    -- Select One --African AmericanSomaliOromoEthiopianNigerianLiberianKenyanSudaneseOther West AfricanOther East AfricanOther North AfricanChoose not to self-identify
80. If "Other" , please describe:
82. Please specify country of origin:
84. If "Other", please specify:
88. Additional Information if you become Board or Commission Member
    Additional information may be emailed to info@cityofroseville.com or delivered to Administration Department, City of Roseville, 2660 Civic Center Drive, Roseville, MN 55113 or faxed to 651-792-7020.
90. Minnesota Government Data Practices Act*

    I understand that information provided in this application 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.

    1. Yes
92. Minnesota Statute §13.601. subd. 3(b)*

    Occasionally, City staff receive requests from the media or from the public for ways to contact Commission members. The Commission roster is periodically made available. Under Minnesota Statute §13.601. subd. 3(b), either a telephone or electronic mail address (or both) where you can be reached must be made available to the public. Please indicate which contact method the City may make available for inclusion on the Commission roster.

    1. Home/Cell Phone
    2. Email Address
94. Background Authorization*

    I understand that the Commission position for which I am applying may require the City of Roseville to perform a background check. As a result, an investigation may be made in which information is obtained through personal interview(s), information held by law enforcement or governmental agencies, present or former employers, financial institutions, or references I have provided. I understand that the City of Roseville will use the services of the Roseville Police Department to assist with the research and verification of the information I have provided on my application. The City of Roseville will utilize various sources of information it deems appropriate, including, but not limited to, credit reporting agencies, Department of Motor Vehicles records, criminal conviction records, current and former employers, military records, education records, and professional and personal references. I request, authorize and consent to the release and disclosure of any and all information, including, but not limited to, the above to the City of Roseville and the Roseville Police Department, and hereby expressly release any person who provides information pursuant to this investigation from any claims or liability by me or on my behalf.

    1. Yes
96. Acknowledgement*

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

    1. Yes
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit Submit and Print

* indicates a required field