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7. Porubcansky application[RE:EIVEDSCDIA SCANDIA Application for Appointment To Commission or Committee Committee/Area of Interest : 10 kkri So,' 0 &Vt m t L e,0_ Name: Home Phone: Home Address: I gW10 0 rujel1 A - ,e- NS _ Zip: 55-0 9-7 E -Mail Address:(ZJ�ip S k ajM CE & . U t'YN How long have you been a resident of Scandia? ✓r S vea('S Property owned in Scandia (other than residence): Employment Present Employer: (;w m e[ 1 RY) M we I_wl Worked There Since (mo/yr): 5` Work Phone: 6 1- 3 $3 ---? *3S 1 Position Title: eOVY7 ffluni D ireCS 6(- Commission/Committee Experience Commission/ Committee Dates Served Educational Background Highest Level Achieved (degree/major): 19/4 - Imo,t'W�� Other Experience List any governmental, service organizations, or professional activities which you have been or currently are involved in: Wn ct e r A ScrAn �" a- r`eq-m Qfs 6 a r-1 :A In what volunteer activities have you participated? What was your role? 15'e_*_- aSW JQ�, In accordance with M.S. 13.04 Subd. 2 we must inform you of your rights as a subject of government data. The information you give us about yourself is needed to identify you and assist in determining your suitability for the positions(s) for which you are applying. The information that we collect about you is classified as either Public or Private. Public means that it is available to anyone who asks to see it. Private means that the information is available only to the person the information is about and to the staff who must use it in the normal course of conducting City business and as otherwise provided for by law. As the person executing this application, I acknowledge that an investigation may be conducted for use 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. I hereby release the City and any organization, company or person furnishing information to the City, as expressly authorized above, from any liability for damage which may result from furnishing the information requested. Signature: Date: %//7//R 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 Commission or Committee. Return completed application to: City of Scandia 14727 209th Street North Scandia, MN 55073 Phone: 651.433.2274 Fax: 651.433.5112 E-mail: k.cammilleri@ci.scandia.mn.us