APPLICATION FOR BOARD OR COMMISSION
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Citizens Advisory Committee
Data Privacy Information
The information provided by you on this application will be used to determine your suitability for appointment to a board or commission with the City of Maple Grove
and to provide you with information pertaining to your application for this committee or board. If you are selected, a list containing your name, address and telephone
number(s) will be distributed to appropriate staff. Participation as a board/commission member is strictly voluntary, and you are not required by law to furnish any
of the information requested on this application. If you do not furnish this information, however, we may have trouble determining your suitability for appointment,
contacting you with information regarding your application and, if selected, with your duties on the board or commission.
Under Minnesota State statutes, the following information about you is public: name, city of residence, education and training, employment history, volunteer work,
awards and honors, and prior government service or experience. Once an individual is appointed to a public body, the following additional items of data are public:
residential address; and either a telephone number or electronic mail address where the appointee can be reached. Any other information collected on this application
form is private data and will be accessible only to you, pertinent City of Maple Grove staff, or as provided for by Minnesota statutes.
Name Maple Grove Resident (# of years)
Address
Home Phone Cell Phone
Email Occupation
Name of Employer Work Phone
Education (highest grade completed or highest degree and major course of study)
Civic and other activities (past and present civic activities and organizational memberships, particularly
those relevant to the appointment you are seeking)
Comments (briefly describe qualifications, experience, or other information you would like the city to
consider or which you believe are relevant to the appointment you are seeking)
(office use only ~ Application will be retained one-year from date received.)
Date Application Received _______________ Date Applicant Appointed ___________________
Return application to: City of Maple Grove | 12800 Arbor Lakes Pkwy | Maple Grove, MN 55369
