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Citizen Advisory Commission Application
Name
Date
Address
Home Phone
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Employer
Work Phone
Occupation
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E-mail
Please rank in order the commissions on which you would like to serve (leave blank any on which you do not
wish to serve):
Advisory Committee on Historic Preservation
Economic Development Authority
Human Services/Human Rights Commission
Parks, Recreation & Natural Resources Commission
Public Works Commission
Arts Commission
Environmental Commission
Public5afety, Health & Welfare Commission
Planning Commission
Other:
Do you have any special qualifications that you feel would help you be particularly effective on a commission
(i.e. work experience, volunteer experience, education, hobbies, etc.)?
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List two or three goals that you would like to see accomplished during your term on a commission.
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How did you become interested in serving on a commission?
The City strives to have a variety of people serving on its advisory commissions. The following Information is optional,
but would be helpful to us in achieving our goal of balance.
Gender P17 Age �_ Racial/Ethnic GroupLA / Years as Resident
Return your completed application to:
City of Cottage Grove
ATTN: Commission Application
12800 Ravine Parkway
Cottage Grove, MN 55016
or fax to (651) 458-2897
YOUR APPLICATION WILL BE KEPT ON FILE FOR ONE YEAR AFTER DATE OF SUBMITTAL. PLEASE CONTACT CITY CLERIC CARON
STRANSKY WITH ANY QUESTIONS AT (651) 458-2814.
CITY OF COTTAGE GROVE -,12900 Ravine Parkway Cottage Grove, Minnesota 55016
www.cottage-grove.oi g • 651458,2800 • Fax 651-458-2897 a Equal Oppoitun@y Employer
If appointed to an Advisory Commission, I, tte u4i '2e t ti,ty authorize the
City of Cottage Grove to release the following private data upon r quesmade to the City (check
all that apply). You must choose at least one phone number or e-mail address to be made
public.
Home telephone number b.5 ) V y S q 7
Home email address h r �C .; bt� e��/�Sh. (,GSrj
Work address --
Work telephone number
Work email address
Cell phone number
None of the above
I also authorize the City of Cottage Grove to release such authorized private data referenced
above to members of the general public, City staff, Mayor, and City Council members upon
request for such data. The person(s) receiving such private data must use it only for lawful
purposes.
This authorization shall be modified or cancelled only upon written notice to the City Clerk, City
of Cottage Grove.
I agree to inform the City Clerk's of any change indicated above.
I agree to relinquish and waive all claims that may arise against the City, its agents or employees
for releasing any and all authorized data referenced above relating to this agreement,
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Date Signature
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