5c Planning - BraseRECEIVED
DEC 10 ZU'r )
CITY OF SCANDIA
Application for Appointment
To Commission or Committee
Committee/ Area of Interest: P[3Ay\W,\cA C
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Name: (a t , _ Home Phone: (g 13, a `aqx
Home Address: ZIr
E-Mail Address:
How long have you been a resident of Scandia? 1 V'_-
Property owned in Scandia (other than residence):
Employment I I_ t9�10
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Present Employer euk?'j Worked There Since (mo/yr) J `J
Work Phone 5� Position Title -<-I/O,�
Commission/Committee Experience
Commission/ Committe4jtL�,,Y. 4�u1rYur 'erved C;Z 's
MR 141 ram► 1(3
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educational Background
Highest Level Achieved (degree/major)
Other Experience
List any governmental, service organizations, or professional activities which you have been or
currently are involved in: — 4 L rJ I c
In what volunteer activities have you participated? What was your role?
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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 di information requested.
Signature: (J" t 1Y 6nuxi—_ Date:
You may attach a resume ifyou 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 St. N.
Scandia, MN 55073
Phone: 651 433-2274 Fax: 651 433-5112
E-mail: mail@ci.scandia.mn.us