5.a Hegland applicationSCANDIA
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Application for Appointment
To Commission or Committee
Committee/ Area of Interest : �ri[6in�n�1 ( o m 1411, 4 fcC_
Name: _ �'�-S '� l ' e_ j ck�_Home Phone: .. 612- — 7q 7 ` I17
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Home Address: 2 S 3 �`Ji'�✓D Ave-, ZIP �S-n ? 3
E -Mail Address: Oj I e `
How long have you been a resident of Scandia?
Property owned in Scandia (other than residence): M. f) ne_-
Employment
Present Employer S�If' Worked There Since (mo/yr)
Work Phone IL- 7 r 7— 47 Position Title awn
(. o"omission/Committee Experience
4'1Commission/ Committee PCk('k Ck �� [ t-er��ia �pates �MMServed v 3/ t 6
��✓n�ore�i�/lSiVe PICt", ,Z e -C17
Educational Background
Highest Level Achieved (degree/major) Syme 67 11, cL
Other Experience
List any governmental, service organizations, or professional activities which you have been or
currently are involved in: _ civ- �� a� Re CO M/"; Cct ,,� �
�t ut r'o �cr,,,s'i�- Cts /✓l/n � �C � � t7j7'1 re�� / t � ! �ct.�-�'y��e/'r�l�ti
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In what volunteer activities have you participated? What was your role?
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In atccordance with M.S. 13.04 Sub& 2 we must infornm you of your rights as a suhieet of government data. The
information you give us about yourself is needed to identify you and assist in dctcrutining your suitability for the
positians(s) for whiclt you are applying. The infunnation that we collect about you is classified its either Public or Private.
Public means fliat it is available to anyone who asks to see it. Private means that the utfortmation is available only to the
person the information is about and to the staff who must use it in the normal COUTSC of conducting City business and as
otherwise provided for by law.
As the person executing this application, l acknowledge that an invesdgalion may be conducted for tine in determining my
qualifications, i hereby expressly authorize release of any and all information which any organization, company or person
may have. including information of a confidential or privileged nature. 1 hereby release the City and any organization,
company or person tarnishing infbrmation to the City, as expressly authorized above, from any liability for damage which
may result from furnishing the information requested.
Signature: ._ Date: 1 O Z 3 A 7
You may attach a resume if you desire. The selection process will vary according to the number of
applicants and vacancies and may include interviews. Your application will be kept on file for one
year. Thank you for your interest in serving on a Cotrnnission or Committee.
Return completed application to: City of Scandia
14727 209" St. N.
Scandia, MN 55073
Phone: 651 433-2274 Fax: 651 433-5112
E-mail: mail&i.scandia.mn.us