3. Bohrer application_Wastewater Committee* Firs Name
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* Email
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SCANDIA
14727 209th St North
Scandia, MN 55073
(651) 433-2274;s:e�ti il; Of;c tltrli :::tri
Application for Appointment
To Commission or Committee
Phone
Last Name
Ex. (123) 456-7890
* Address * How long have you been a resident in Scandia?
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* Name of Commission or4ommitteeou areapplying for:
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* Have you served on any Scandia Commission or Committee?
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If yes, please indicate which one and when
RECEIVED
JAN 0 4 2022
CITY OF SCANDIA
* List any governmental, service organizations, or professional activities which you have been or currently are involved in:
List any of your special interests, activities or hobbies which you have that would apply to this committee:
This is optional
* 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.
By checking this box, I am affixing my signature to this application and acknowledging 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.
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Aeov'es, I agree to this as my signature
'❑ No, I do not agree this as mei signature
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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.
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