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2014.12.02 Work Session Packet (1st)4141 Douglas Drive North • Crystal, Minnesota 55422-1696 Tel: (763) 531-1000 • Fax: (763) 531-1188 • www.crystalmn.gov AL CRYSTAL CITY COUNCIL FIRST WORK SESSION AGENDA Tuesday, December 2, 2014 6:30 p.m. Conference Room A Posted: November 26, 2014 Pursuant to due call and notice given in the manner prescribed by Section 3.01 of the City Charter, the first work session of the Crystal City Council was held at p.m. on Tuesday, December 2, 2014 in Conference Room A located at 4141 Douglas Drive, Crystal, Minnesota. I. Attendance Council members Staff Deshler Norris Hoffmann Therres Libby Peak Selton Adams Budziszewski II. Agenda The purpose of the work session is to: • Discuss West Metro Fire -Rescue District Update • Meet with Charter Commission applicants III. Adjournment The work session adjourned at p.m. Revering Larson Norton Serres Auxiliary aids are available upon request to individuals with disabilities by calling the City Clerk at (763) 531-1145 at least 96 hours in advance. TTY users may call Minnesota Relay at 711 or 1-800-627-3529. Memorandum CITY of CRYSTAL DATE: November 25, 2014 TO: Mayor and City Council FROM: Anne Norris, City Manager SUBJECT: Quarterly West Metro Fire -Rescue District Update Chief Sarah Larson and Board Crystal Citizen Representative Mary Serie will be at the December 2 work session to provide a brief update on District and Board activities. Chief Larson will report on District staffing and recent emergency preparedness training with both city staffs as well as other training. Memorandum CITY of CRrsT AGG DATE: November 25, 2014 TO: Mayor and City Council FROM: Anne Norris, City Manager SUBJECT: Charter Commission Candidates There are currently five applicants for one vacancy on the Charter Commission. As you recall, appointments to the Charter Commission are made by the Chief Judge of the Hennepin County District Court. The Council's practice has been to have a brief work session with Charter Commission applicants to get a chance to meet the applicants. The five applicants, David Anderson, John Budziszewski, Mark Hoffmann, Nancy LaRoche and James Oathout will be at the December 2 work session. Attached are the candidates' applications. 1/ V APPLICATION FOR CITY BOARDS & COMMISSIONS ciry 'CRtorYSTAL Return application to: 4141 Douglas Drive N, Crystal MN 55422 Fax: (763) 531-1188; Email: trudy.tassoni@crystalmn.gov. V-1 Please check one: [ New Applicant ❑ Reappointment Thank you for your interest in serving your community as a volunteer. Please indicate below the board or commission which you would like to be appointed to. (Note eligibility requirements - a member of a board or commission must be a lawful resident of Crystal and, if required, a resident of the Council ward from which they are appointed.) Your application will be kept on file for one year. a Charter Commission ❑ Parks & Recreation Commission (Ward ) ❑ Employee Review Board ❑ Planning Commission (Ward ) ❑ Environmental Quality Commission ❑ Watershed Mgt Organization — Bassett Creek ❑ Human Rights Commission ❑ Watershed Mgt Organization —Shingle Creek ❑ NW Hennepin Human Services Council ❑ West Metro Fire Board PERSONAL INFORMATION (please pri nt) Name n 0.,ul 4 6 /'- n Length of residence in Crystal First Middle Last Street Address _ Home Phone _ Work Phone Cell Email Employer, _Occupation CU./ d t Gt IXIe�-j s d r.P r yv STATEMENT OF INTEREST j Why are you interested in serving on this City board or commission? I Mr-, l✓1 �� S t Yn 3'e—r\1IrV Mhq COmmJ Yti C r�i IMPORTANT ISSUES FACING OUR COMMUNITY What do you think are the most important issues facing our community over the next several . 6L/)jyears? s4y-ta M0,N1 '?_ncL',nr1 rtcc7) ArVC;k1'6D!1 PIQ the new OUb)ic 1A10C Describe what issues and ideals youlwoul like to see addressed by the board or commission you would like to serve on. ran k. �i L�O1[' 2 V d Ln 0 I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 1 of 3 COMMUNITY, CIVIC, OR VOLUNTEER EX PFjRIF,NCF 1 � Please list our volunteer experience. i r� S ffJJ yin n )n m 1S S'16Y1 ATTENDANCE AND CONFLICT OF INTEREST Are you aware of the meeting schedule for this board or commission and are you able to attend meetings regularly? Yes_ No (For reappointments only: If you have not been able to attend meetings regularly, please explain: A conflict of interest may arise by your participation in an activity, action, or decision from which you receive or could potentially receive direct or indirect personal financial gain. Do you have any legal or equitable interest in any business which, in the course of your participation on this board or commission, could give rise to a conflict of interest? Yes No /\ (If yes, please provide details on a separate sheet of paper.) As a board or commission member, what issue(s) might cause conflict between your civic responsibility and personal or professional interests? How would you manage these conflicts? �P NEW APPLICANTS ONLY: Have you attended and observed a commission meeting for which you've made application? Yes, on .- O I Not yet, but I will attend a meeting on (date of meeting) (date of meeting) EDUCATION AND PROFESSIONAL EXPERIENCE Describe your education and/or professional experience. 6,S- (�usin,,e..-S A4min)S�,(4)0'r UntvQ-rsn ► 6�/1�ir>7cS6 Q ra,dvo�c. kN orl(lr^ reGCotir.T)IIQ UhtVtrs tty 0T /VLP14 r - S-6 to w l l 1 a,,,,, /►� duh e,) I cal 1 �o o f L�� REAPPOINTMENTS ONLY: COMMISSION OR BOARD HIGHLIGHTS Describe a highlight(s) or accomplishments) of the board or commission during your last term. I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 2 of 3 IMPORTANT INFORMATION CONCERNING YOUR APPLICATION DATA PRIVACY NOTICE: Minnesota law requires that you be informed of the purposes and intended use of the information you are providing on this application. Pursuant to Minn. Stat. §13.601, your name, address, length of residence, occupation, education, training, civic affiliations, qualifications, and experience are public data and is available to anyone who requests the information. The information you provide will be used to identify you as an applicant, enable us to contact you when additional information is required, send you notices, and assess your qualifications for appointment. This data is not legally required, but refusal to supply the information requested may affect the City Council's ability to accurately evaluate your application. Should you be appointed to a board or commission, pursuant to Minn. Stat. §13.601, your residential address will become public information. In addition, either a telephone number or email address where you can be reached will become public. The purpose is to list contact information for commission members on a public roster. Please select which of the following you will allow listed on a public roster (you must select either email or one phone number): ❑ EMAIL OR CHO� (may choose more than one): home ❑ work ❑ cell ❑ ALL OF THE ABOVE 1 have read the data privacy notice given above and authorize investigation into all statements contained in this application. Furthermore, 1 authorize the City of Crystal to conduct a criminal history background check, pursuant to Crystal City Code Section 311.01, Subd. 2, for purposes of determining my eligibility for a volunteer position with the City. MN Driver's License or MN State ID Number:. If known by previous name, provide: N -t -n--2 , A a- NovY Applicant's signature Date ••...•.......•.•..•.......••••••........•.•••......•.•..••.............•............•••..••.............•..••......•.••....•......•..••.......................•..........•..... .y Process Step 1 Complete an application Step 2 Return the completed application to the administrative services coordinator Step 3 Participate in a 15 -minute interview with the mayor or mayor pro tem, commission chair, and council liaison of the commission Step 4 New applicants only: attend a council meeting to be formally appointed to the commission ...................................................................................................................................................................................................... I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 3 of 3 f QV0111 �olrr APPLICATION FOR ary BOARDS & COMMISSIONS C AL Return application to: 4141 Douglas Drive N, Crystal MN 55422 Fax: (763) 531-1188; Email: trudy.tassoni@crystalmn.gov. / Please check one: New Applicant ❑ Reappointment Thank you for your interest in serving your community as a volunteer. Please indicate below the board or commission which you would like to be appointed to, (Note eligibility requirements - a member of a board or commission must be a lawful resident of Crystal and, if required, a resident of the.Council ward from which they are appointed.) Your application will be kept on file for one year. �harter Commission ❑ Parks & Recreation Commission (Ward ) ❑ Employee Review Board ❑ Planning Commission (Ward ) ❑ Environmental Quality Commission ❑ Watershed Mgt Organization — Bassett Creek ❑ Human Rights Commission ❑ Watershed Mgt Organization —Shingle Creek ❑ NW Hennepin Human Services Council ❑ West Metro Fire Board I:'ri$K SONAi., Il'*1Ff91!liMA'01CM Name oma Length of residence in Crystal First Middle Last Street Address Home Phone _ Work Phone Cell Ema I, Employer _Occupation iI'A'VkI'lV; i' f's`A' OF MTlII`RF,' v'I' Why are you interested in serving on this City board o mmissiioon? Ito& OUR 4.;O[vil\':{ _ NT'll"Y What do you think are the most iMig tant issues facing our community over the next/ ral years? rr�z. mss, , r ac�Y ,,� fo Describe what issues and ideas Pu would like to see addressed by the board or commission you would like to serve on, '�t>s►%� I:\Commissions\Vacancies\Application For City hoards And Commissions.Doc Page 1 of 3 °i�t_�f,a}1?I`.r E:1,:p VMX11*' i':fI l }'f :p PI a e lis your volunte e erience. ` x Alt, iiji 6 d Are you aware of the meeting s edule for this board or commission and are you able to attend meetings regularly? Yes No (For reappointments only: If you have not been able to attend meetings regularly, please explain: A conflict of interest may arise by your participation in an activity, action, or decision from which you receive or could potentially receive direct or indirect personal financial gain. Do you have any legal or equitable interest in any business which, in the course of your participatiFr'this board or commission, could give rise to a conflict of interest? Yes No dd (If yes, please provide details on a separate sheet of paper.) As a board or commission member, what issue(s) might cause conflict between your civic responsibility and personal or professional interests? How would you manage these conflicts? NEW APPLICANTS ONLY: Have you attended and observed a commission meeting for which you've made application? Yes, on Not yet, but I will attend a meeting on (date of meeting) (date of meeting) I43:3tlt;A1'it.)N.ANR)I"R€ FF'SSIibNA.}.. Describe your education and/or professional experience. REAPPOINTMENTS ONLY: Y,t.>IVIMI<aSI N ,OR BOARI.) �IIt II1.,ifMII'k'`� Describe a highlight(s) or accomplishments) of the board or commission during your last term. is\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 2 of 3 £Ilf4n€"►fw`I'� i�S' ` 11\ft"{olti'11f `f'1€ti"� t:ON€ €M.1411N€: DATA PRIVACY NOTICE: Minnesota law requires that you be informed of the purposes and intended use of the information you are providing on this application. Pursuant to Minn. Stat. §13.601, your name, address, length of residence, occupation, education, training, civic affiliations, qualifications, and experience are public data and is available to anyone who requests the information. The information you provide will be used to identify you as an applicant, enable us to contact you when additional information is required, send you notices, and assess your qualifications for appointment. This data is not legally required, but refusal to supply the information requested may affect the City Council's ability to accurately evaluate your application. Should you be appointed to a board or commission, pursuant to Minn. Stat. §13.601, your residential address will become public information. In addition, either a telephone number or email address where you can be reached will become public. The purpose is to list contact information for commission members on a public roster. Please select which of the following you will allow listed on a public roster (you must select either email or one phone number): MAIL OR PHONE (may choose more than one): home ❑ work 0 cell ❑ ALL OF THE ABOVE 1 have read the data privacy notice given above and authorize investigation into all statements contained in this application. Furthermore, 1 authorize the City of Crystal to conduct a criminal history background check, pursuant to Crystal City Code Section 311.01, Subd. 2, for purposes of determining my eligibility for a volunteer position with the City. MN Driver's License or MN State ID Number: me, p de: Applican/signature Date ..................................................................................................................................................................................................... Process Step 1 Complete an application Step 2 Return the completed application to the administrative services coordinator Step 3 Participate in a 15 -minute interview with the mayor or mayor pro tem, commission chair, and Council liaison of the commission Step 4 New applicants only: attend a council meeting to be formally appointed to the commission ................................................................................................................................................................................I....................: I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 3 of 3 jL APPLICATION FOR CITY BOARDS & COMMISSIONS CITY of CRYSTAL Return application to: 4141 Douglas Drive N, Crystal MN 55422 Fax: (763) 531-1188; Email: trudy.tassoni@crystalmn.gov. Please check one: New Applicant ❑ Reappointment Thank you for your interest in serving your community as a volunteer. Please indicate below the board or commission which you would like to be appointed to. (Note eligibility requirements - a member of a board or commission must be a lawful resident of Crystal and, if required, a resident of the Council ward from which they are appointed.) Your application will be kept on file for one year. [Charter Commission ❑ Employee Review Board ❑ Environmental Quality Commission ❑ Human Rights Commission ❑ NW Hennepin Human Services Council ❑ Parks & Recreation Commission (Ward ) ❑ Planning Commission (Ward ) ❑ Watershed Mgt Organization — Bassett Creek ❑ Watershed Mgt Organization — Shingle Creek ❑ West Metro Fire Board PERSONAL INFORMATION (please print Name /g�,� �%Y%012 1 /,� Length of residence in Crystal First Street Address _ Home Phone Cell Email Work Phone Employer /`<Yy ell Occupation STATEMENT OF INTEREST Why are you interested in serving on this City board or commission? Z`k 0 ORTANT ISSUES FACING OUR COMMUNITY What do you think are the most important issues facing our community over the next several Describe what issues and ideas you would like to see addressed by the poara or commission you V u 1:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 1 of 3 T COMMUNITY, CIVIC, OR VOLUNTEER EXPERI Please list your volunteer experience. w � .. 0 // ATTENDANCE AND CONFLICT OF INTEREST Are you aware of the meeting schedule for this board or commission and are you able to attend meetings regularly? Yes No t/ (For reappointments only: If you have not been able to attend meetings regularly, please explain: A conflict of interest may arise by your participation in an activity, action, or decision from which you receive or could potentially receive direct or indirect personal financial gain. Do you have any legal or equitable interest in any business which, in the course of your participation this board or commission, could give rise to a conflict of interest? Yes No (If yes, please provide details on a separate sheet of paper.) As a board or commission member, what issue(s) might cause conflict between your civic res onsibility and personal or professional interests? How would you manage these conflicts? �4�1P NEW APPLICANTS ONLY: Have you attended and observed a commission meeting for which you've made application? Yes, on /o y / Not yet, but I will attend a meeting on (date If eting) (date of meeting) EDUCATION AND PROFESSIONAL EXPERIENCE Describe your education and/or professional experience. - Us/hPss�Y��L1/�!°sldS'Y�+ REAPPOINTMENTS ONLY: COMMISSION OR BOARD HIGHLIGHTS Describe a highlight(s) or accomplishment(s) of the board or commission during your last term. I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 2 of 3 IMPORTANT INFORMATION CONCERNING YOUR APPLICATION DATA PRIVACY NOTICE: Minnesota law requires that you be informed of the purposes and intended use of the information you are providing on this application. Pursuant to Minn. Stat. §13.601, your name, address, length of residence, occupation, education, training, civic affiliations, qualifications, and experience are public data and is available to anyone who requests the information. The information you provide will be used to identify you as an applicant, enable us to contact you when additional information is required, send you notices, and assess your qualifications for appointment. This data is not legally required, but refusal to supply the information requested may affect the City Council's ability to accurately evaluate your application. Should you be appointed to a board or commission, pursuant to Minn. Stat. §13.601, your residential address will become public information. In addition, either a telephone number or email address where you can be reached will become public. The purpose is to list contact information for commission members on a public roster. Please select which of the following you will allow listed on a public roster (you must select either email or one phone number): MEM'AIL OR PHONE (may choose more than one): M home ❑ work ❑ cell ❑ ALL OF THE ABOVE I have read the data privacy notice given above and authorize investigation into all statements contained in this application. Furthermore, I authorize the City of Crystal to conduct a criminal history background check, pursuant to Crystal City Code Section 311.01, Subd. 2, for purposes of determining my eligibility for a volunteer position with the City. MN Driver's License or MN State ID Number: V I PAO a n, ; 11 0 0 Al At ///V Jill J, Dat r...................................................................................................................................................................................................., Process Step 1 Complete an application Step 2 Return the completed application to the administrative services coordinator Step 3 Participate in a 15 -minute interview with the mayor or mayor pro tem, commission chair, and council liaison of the commission Step 4 New applicants only: attend a council meeting to be formally appointed to the commission :.................................................................................................................................................................................................... : I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 3 o 3 APPLICATION FOR CITY BOARDS & COMMISSIONS CITYIoI xYSTAt Return application to: 4141 Douglas Drive N, Crystal MN 55422 Fax: (763) 531-1188; Email: trudy.tassoni@crystalmn.gov. Please check one: XNew Applicant ❑ Reappointment Thank you for your interest in serving your community as a volunteer. Please indicate below the board or commission which you would like to be appointed to. (Note eligibility requirements - a member of a board or commission must be a lawful resident of Crystal and, if required, a resident of the Council ward from which they are appointed.) Your application will be kept on file for one year. 9 Charter Commission ❑ Parks & Recreation Commission (Ward ) ❑ Employee Review Board ❑ Planning Commission (Ward ) ❑ Environmental Quality Commission ❑ Watershed Mgt Organization — Bassett Creek ❑ Human Rights Commission ❑ Watershed Mgt Organization — Shingle Creek ❑ NW Hennepin Human Services Council ❑ West Metro Fire Board PERSONAL INFORMATION (please print) Name IA N(-� 1��-LeNC (A � � Length of residence in Crystal 1-7 y First Middle Last Street Address _ Home Phone Ik/ Work Phone Cell Employer Email Occupation 6,eAftliC-� DCSt�ti►,�- STATEMENT OF INTEREST Why are you interested in serving on this City board or commission? CV/�iT ('�-V-4' E�Jft GI r' V0,1 b3 .-n>r? t ITY - - lei Ni Mils r 4 �-A (,rt4-r IMPORTANT ISSUES FACING OUR COMMUNITY What do you think are the most important issues facing our community over the next several years? ( �L(.` - y s ��rt.'.1 ?"`/ �- 'TN`s C�4 `T, 4 1 t"5y? ;—,-,�5- U t (�'�-�'yCZ 15 j4�'S��'c�lr gat �' L��I,h!�r:✓`�I�l i 1' '� )S ,4000CATi Nu A-1,luA-(5 F -G. A C' -f 15 SAFf- 4- �✓�5�'Z�iIJ� - Describe what issues and ideas you would like to see addressed by the board or commission you would like to serve on. 11�t � Y �Sr (�i)� ce Wwo {mss 6LU'il r-og A L6 M CAA—ti( 1-1 % C4 I -D �5 L21, i'ITH T2&A �.. UG- t I'M AV50 4 `i��t'n� �L SG P► 5i ZW,, f��]�Iy Fxl-rcL-5S <Y %camN !,t t. P(-10 A 4A'aa� s" -D4 &t#,A:C+ r77- I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 1 of 3 COMMUNITY, CIVIC, OR VOLUNTEER EXPERIENCE Please list your volunteer experience. FjU-1 4C<;; Cot, NJ k< OA , C'tZ�SI-lJ L eo t, -kA 1>5i Q P,� L, ('PrVf;J'1'( Qe-Loy �rTi� i5Uii''� k 11L&Zj'l ATTENDANCE AND CONFLICT OF INTEREST Are you aware of the meeting schedule for this board or commission and are you able to attend meetings regularly? Yes_, No (For reappointments only: If you have not been able to attend meetings regularly, please explain: A conflict of interest may arise by your participation in an activity, action, or decision from which you receive or could potentially receive direct or indirect personal financial gain. Do you have any legal or equitable interest in any business which, in the course of your participation on this board or commission, could give rise to a conflict of interest? Yes No %, (if yes, please provide details on a separate sheet of paper.) As a board or commission member, what issue(s) might cause conflict between your civic responsibility and personal or professional interests? How would you manage these conflicts? NEW APPLICANTS ONLY: Have you attended and observed a commission meeting for which you've made application? Yes, on Not yet, but I will attend a meeting on NLx-' Cr4L44n JET&, (date of meeting) (date of meeting) EDUCATION AND PROFESSIONAL EXPERIENCE Describe your education and/or professional experience. JOLLE6t : C(4-ADiD /-'v REAPPOINTMENTS ONLY: COMMISSION OR BOARD HIGHLIGHTS Describe a highlight(s) or accomplishment(s) of the board or commission during your last term. I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 2 of 3 IMPORTANT INFORMATION CONCERNING YOUR APPLICATION DATA PRIVACY NOTICE: Minnesota law requires that you be informed of the purposes and intended use of the information you are providing on this application. Pursuant to Minn. Stat. §13.601, your name, address, length of residence, occupation, education, training, civic affiliations, qualifications, and experience are public data and is available to anyone who requests the information. The information you provide will be used to identify you as an applicant, enable us to contact you when additional information is required, send you notices, and assess your qualifications for appointment. This data is not legally required, but refusal to supply the information requested may affect the City Council's ability to accurately evaluate your application. Should you be appointed to a board or commission, pursuant to Minn. Stat. §13.601, your residential address will become public information. In addition, either a telephone number or email address where you can be reached will become public. The purpose is to list contact information for commission members on a public roster. Please select which of the following you will allow listed on a public roster (you must select either email or one phone number): MEMAIL OR PHONE (may choose more than one): ❑ home ❑ work ❑ cell ❑ ALL OF THE ABOVE 1 have read the data privacy notice given above and authorize investigation into all statements contained in this application. Furthermore, 1 authorize the City of Crystal to conduct a criminal history background check, pursuant to Crystal City Code Section 311. 01, Subd. 2, for purposes of determining my eligibility for a volunteer position with the City. MN Driver's License or MN State ID Number: If knoyvn by previous name, provide: Applicant's iignature i1 ' I I q. Date ..................................................................................................................................................................................................... . Process Step 1 Complete an application Step 2 Return the completed application to the administrative services coordinator Step 3 Participate in a 15 -minute interview with the mayor or mayor pro tem, commission chair, and council liaison of the commission Step 4 New applicants only: attend a council meeting to be formally appointed to the commission .................................................................................................................................................................................................... r I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 3 of 3 CofAPPLICATION FOR CITY BOARDS & COMMISSIONS AL Return application to: 4141 Douglas Drive N, Crystal MN 55422 Fax: (763) 531-1188; Email: tru_dy.tassoni@crystalmn.gov. Please check one: ❑ New Applicant Reappointment Thank you for your interest in serving your community as a volunteer. Please indicate below the board or commission which you would like to be appointed to. (Note eligibility requirements - a member of a board or commission must be a lawful resident of Crystal and, if required, a resident of the Council ward from which they are appointed.) Your application will be kept on file for one year. LR Charter Commission ❑ Parks & Recreation Commission (Ward ) ❑ Employee Review Board ❑ Planning Commission (Ward ) ❑ Environmental Quality Commission ❑ Watershed Mgt Organization — Bassett Creek ❑ Human Rights Commission ❑ Watershed Mgt Organization —Shingle Creek ❑ NW Hennepin Human Services Council ❑ West Metro Fire Board PERSONAL INFORMMATION (please print) Name JannQs 1 OWELI_ DA"rwUT— Length of residence in Crystal kyr First Middle Last Street Address -Zip Home Phone Work Phone Cell Email Employer Occupation DBA STATEMENT OF INTEREST Why are you interested in serving on this City board or commission? Circ r6uoLjjPpLAA& . IMPORTANTISSUES FACING OUR COMMUNITY What do you think are the most important issues facing our community over the next several years? &oh Describe what issues and ideas you would like to see addressed by the board or commission you I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 1 of 3 C- COMMUNITY, CIVIC, OR VOLUNTEER EXPERIENCE Please list your volunteer experience. -CWEAL VV1 AL U42-1" 11. COIF COW Auto llC&6rJy►S ATTENDANCE AND CONFLICT OF INTEREST Are you aware of the meeting schedule for this board or commission and are you able to attend meetings regularly? Yes i0 No (For reappointments only: If you have not been able to attend meetings regularly, please explain: ► � ` Ita � a� � ! A conflict of interest may arise by your participation in an activity, action, or decision from which you receive or could potentially receive direct or indirect personal financial gain. Do you have any legal or equitable interest in any business which, in the course of your participation on this board or commission, could give rise to a conflict of interest? Yes No >0 (If yes, please provide details on a separate sheet of paper.) As a board or commission member, what issue(s) might cause conflict between your civic responsibility and personal or professional i terests? How would you minagethese conflicts? NEW APPLICANTS ONLY: Have you attended and observed a commission meeting for which you've made application? Yes. on Not yet, but I will attend a meeting on (date of meeting) EDUCATION AND PROFESSIONAL EXPERIENCE Describe your education and/or professional experience. COMMISSION OR BOARD HIGHLIGHTS (date of meeting) I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 2 of 3 IMPORTANT INFORMATION CONCERNING YOUR APPLICATION DATA PRIVACY NOTICE: Minnesota law requires that you be informed of the purposes and intended use of the information you are providing on this application. Pursuant to Minn. Stat. §13.601, your name, address, length of residence, occupation, education, training, civic affiliations, qualifications, and experience are public data and is available to anyone who requests the information. The information you provide will be used to identify you as an applicant, enable us to contact you when additional information is required, send you notices, and assess your qualifications for appointment. This data is not legally required, but refusal to supply the information requested may affect the City Council's ability to accurately evaluate your application. Should you be appointed to a board or commission, pursuant to Minn. Stat. §13.601, your residential address will become public information. In addition, either a telephone number or email address where you can be reached will become public. The purpose is to list contact information for commission members on a public roster. Please select which of the following you will allow listed on a public roster (you must select either email or one phone number): PS EMAIL OR PHONE (may choose more than one): M home ❑ work ❑ cell F�l ALL OF THE ABOVE 1 have read the data privacy notice given above and authorize investigation into all statements contained in this application. Furthermore, 1 authorize the City of Crystal to conduct a criminal history background check, pursuant to Crystal City Code Section 311. 01, Subd. 2, for purposes of determining my eligibility for a volunteer position with the City. MN Driver's License or MN State ID Number:_ If known by previous name, provide: mv4-11-07 Ti i . cant's signature Date r.................................................................................................................................................................................................... Process Step 1 Complete an application Step 2 Return the completed application to the administrative services coordinator Step 3 Participate in a 15 -minute interview with the mayor or mayor pro tem, commission chair, and council liaison of the commission Step 4 New applicants only: attend a council meeting to be formally appointed to the commission ....................................................................................................................................................................................................., I:\Commissions\Vacancies\Application For City Boards And Commissions.Doc Page 3 of 3