Fillable Citizen Advisory Commission Application (City of Cottage Grove)

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Citizen Advisory Commission Application (City of Cottage Grove)

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CITY OF COTTAGE GROVE
12800 Ravine Parkway
Cottage Grove, Minnesota 55016
www.cottage-grove.org 651-458-2800 Fax 651-458-2897 Equal Opportunity Employer
Citizen Advisory Commission Application
Name
Date
Address
Home Phone
Employer
Work Phone
Occupation
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 Arts Commission
Economic Development Authority Parks, Recreation & Natural Resources Commission
Planning Commission Public Services 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.)?
List two or three goals that you would like to see accomplished during your term on a commission.
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 _______ Age _______ Racial/Ethnic Group _______ Years as Resident _______
Return your completed application to: City of Cottage Grove
ATTN: City Clerk
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 CLERK JOE FISCHBACH
WITH ANY QUESTIONS AT (651) 458-2883.
CONSENT TO RELEASE PRIVATE DATA
Below is an extract of the Minnesota Statutes that explains what data furnished by you is
considered public and private when you apply for an Advisory Commission and if you are
appointed to an Advisory Commission.
13.601 ELECTED AND APPOINTED OFFICIALS.
Subd. 3. Applicants for appointment.
(a) Data about applicants for appointment to a public body collected by a government
entity as a result of the applicant's application for appointment to the public body are
private data on individuals except that the following are public:
(1) name;
(2) city of residence, except when the appointment has a residency requirement that
requires the entire address to be public;
(3) education and training;
(4) employment history;
(5) volunteer work;
(6) awards and honors;
(7) prior government service; and
(8) any data required to be provided or that is voluntarily provided in an application
for appointment to a multimember agency pursuant to section 15.0597.
(b) Once an individual is appointed to a public body, the following additional items of
data are public:
(1) residential address; and
(2) either a telephone number or electronic mail address where the appointee can be
reached, or both at the request of the appointee.
(c) Notwithstanding paragraph (b), any electronic mail address or telephone number
provided by a public body for use by an appointee shall be public. An appointee may
use an electronic mail address or telephone number provided by the public body as the
designated electronic mail address or telephone number at which the appointee can be
reached.
If appointed to an Advisory Commission, I, _______________________________, authorize the
City of Cottage Grove to release the following private data upon request made 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 __________________________
Home email address
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.
__________________________ ______________________________
Date Signature
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Citizen Advisory Commission Application (City of Cottage Grove)

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Completed 21 January 2021

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