2. First Name:*
3. Middle Name:
4. Last Name:*
6. What name would you like to be displayed on your name tag?*
7. Shirt Size*
   -- Select One --Small - SMedium - MLarge - LExtra Large - XL2XL3XLOther
9. Select Commission*
   -- Select One --FinanceHuman Rights, Inclusion, and EngagementParks and RecreationPlanning / VariancePolice Civil ServicePublic Works, Environment, and Transportation
11. Commissioner Handbook*

    I have reviewed and understand the commissioner handbook.

    1. Yes
13. Attendance Policy*

    I understand that I must attend at least 80% of commission meetings. If I am unable to attend a meeting, it is my responsibility to inform the commission chair and staff liaison.

    1. Yes
15. Mandatory Ethics Training*

    As a city leader, I understand that I must attend the ethics training on April 12, 2023 at City Hall or inform the commission staff liaison as soon as possible of any scheduling conflicts.

    1. Yes
17. Please indicate any reasonable accommodation(s) needed in order to participate in commission meetings and general commission activities:
19. Demographic Questionnaire

    The City of Roseville is committed to ensuring a wide variety of perspectives and experiences are represented by our commissioners. The information captured by the Demographics Questionnaire portion of this form will not be made available except in aggregate or statistical analysis of commissioners. This information will be used to help us understand how we can continue to improve our commitment to diversity, and our onboarding and recruitment efforts. 

21. How do you identify your gender?*
    -- Select One --FemaleMaleTransgender FemaleTransgender MaleNon-binary / Non-gender conformingOtherChoose to not self-identify
22. Do you rent or own?*
    -- Select One --RentOwnChoose not to self-identify
24. Do you have a sensory, physical, or mental disability?*
    -- Select One --YesNoChoose to not self-identify
25. What category represents your age?*
    -- Select One --18 - 24 years25 - 39 years40 - 54 years55 - 64 years65+ yearsChoose to not self-identify
27. What was your total household income in the previous year before taxes?*
    -- Select One --Less than $25,000$25,000 - $49,999$50,000 - $74,999$75,000 - $124,999$125,000 - $199,999$200,000 or moreChoose to not self-identify
28. What is the highest level of education you have completed?*
    -- Select One --Some High SchoolHigh School or GEDSome Technical SchoolTechnical School - GraduatedSome CollegeCollege - GraduatedPost GraduateOtherChoose to not self-identify
30. 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 to not self-identify
31. 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/Caucasion
    7. Other race/ethnicity
    8. Choose to not self-identify
33. 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
35. 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
37. 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
38. Dated
    Dated
40. Email Address
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field