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bia.oming}on, minnesota <br />Oity Manager's Office <br /> <br />DATA PRIVACY NOTICE: Your name, current volunteer position <br />and previous work history is public data under the Minnesota Dnta <br />Practices Act. It is available to anyone who requests the <br />information. This data is not legally required but the Oity will not be <br /> <br />'Advisory Board/Commission <br />MEMBERSHIP APPLICATION <br /> <br />able to present information to the City Council without it. The data <br />is needed to distinguish this application from others and to properly <br />exercise the City Council's right to appoint members to advisory <br />boards and commissions. <br /> <br />Name <br /> <br />Employer <br /> <br />Address Zip Position <br />Home Phone B. usiness Phone <br /> <br /> BOARD/COMMISSION Please select one board or commission. <br /> <br />Advisory Board of Health ."--¢ Human Rights Commission ,~--i Traffic & Transportation Advisory Commission <br />Board of Review ~ Parks, Arts & Recreation Commission <br />Housing and Redevelopment Authority ~ Planning Commission <br /> <br />EMPLOYMENT EXPERIENCE As'.cppficable to board/commission membership. <br />CIVIC PARTICIPATION <br /> <br /> BACKGROUND AND INTERESTS <br /> <br /> WHY DO YOU WISH TO BE APPOINTED? <br /> <br />Applicant Signature <br /> <br />Date <br /> <br />The Ci~ of Blooming[on does not discriminate on the basis of disability in <br />the admission or access to, or treatment or employment in, its services, <br />programs, or activities. Upon request, accommodation will be provided to <br />allow individuals with disabilities to participate in all City of Bloomington <br />services, programs, and activities. <br /> <br />The City of Bloomington does not discriminate on the basis of race, color, <br />creed, religion, national origin, sex, sexual orientation, disability, age, <br />marital status or status with regard to public assistance in employment or <br />the provision of services. <br />Upon request, this information can be available in Braille, large print, audio <br />tape and/or computer disk. <br /> <br />1800 West Old Shakopee Road · Bloomington MN 55431-3027 · 952-563-8780 · FAX: 952-563-8754 · TTY: 952-563-8740 . <br /> <br />-222- <br /> <br /> <br />