HomeMy WebLinkAbout15.F.5. Application for Council Advisory Boards and Commissions
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CITY OF SHAKOPEE
.' APPLICATION FOR COUNCIL ADVISORY
BOARDS AND/OR COMMISSIONS
Name: rv\,,~K S. \-\', ( '7-j~S Address: ..., S~~ru:
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E-mail Address: . rr. CDW\
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How long have you been a Shakopee Resident? > i 0 )~C{\(S'
Occupation: Ne..-\--LOl>'C l, Ma.O: rs.\) ~ 2.72-
Place ofEmploymel1t: E d.e.'(\.. PRJ-c.\'<\.e. Sc-h.:c.c\.S
Does your work require you to travel? (Check one)
A great deal Periodically Very Little ~None
Do you have any special interests or training, which you feel a particular board or commission
could 1.1se? (Use a separate she~t if n~cess~) '\ " , L b ' c.1 ~ (l...... VII\.', \ ~ <l if
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Board or Commission in which you are interested? (If more than one, please indicate order of
preference) k t ~U> t~ ~\.{ '\\\ C4 \-~ ~ \')j A,l..v IJ ~ Qo "",,,,',S s ; b"
Please state briefly why you are interested in serving on this Board/Commission for which you
are submitting an applicati n: . -l'^- ,\j L \lcV\
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Conflict of interest is defined as the participation in any activity, recommended action, or
decision from which the individual has or could have the potential to receive personal gain,
whether it be direct or indirect.
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In accordance with this definition, do you have any legal or equitable iuterested iu any,tusiueSS,
however organized, which could be constructed as a conflict of interest? Yes_ No If yes,
please provide the details on a separate sheet of paper.
Please '1Ist three references (Name, Address, Phone):
1. r!\\{. 3te.\le S\ VV\..DV\ g\OO~c.h.oo\ 'R.oetJ 6d.tf'..~~'\.n~\~t-.! 5S3~Y Cf52.-'175"-7()$t
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2. Mt". Jll.e G 802..5 Sc.kb\ ~eJ EJ.e~.pl\J:\i'";e) rn~ S"S3YY 'lS-2.-<175"-iSl
3.M'(. J)~ lot ~ e, I YSJg' W~cJ~\l~~. M'~V\V).e.~j)~ I rMJ5'5'31tS-q5"2-'133-1.l~7~
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I hereby certify that the' facts within the foregoing application are true and con'ect to the best of
my knowledge.
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Date
RETURN APPLICATION AND PLEDGE TO:
City Clerk
City of Shakopee
129 Holmes Street South
Shakopee, MN 55379
952-233-3800
Date Received: 7-/t-tJlI