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2. **information on this application may become public**
4. First Name*
5. Last Name*
6. Date Submitted*
   Date Submitted
8. Street Address*
9. Apt #
11. City*
12. State*
13. Zip*
15. Phone*
16. Fax
18. E-mail*
    If not available, enter "None."
20. Business Name
22. Business Address
24. Business Phone
25. Business Fax
27. Business E-mail
29. Board/Commission applying for:*
    -- Select One --Adult Mental Health Advisory CommitteeBoard of AdjustmentChildren's Mental Health Advisory and Coordination CouncilCommunity Corrections Advisory BoardCommunity Health Advisory CommitteeCoon Creek Watershed DistrictEmergency Medical Services CouncilInternal Audit CommitteeLibrary BoardMinnesota Extension CommitteePersonnel Board of AppealsRice Creek Watershed DistrictWorkforce Development BoardOther

    Please confirm you meet the requirements under the Powers, Duties and Responsibilities; Meeting Schedule; and Vacancy Criteria before submitting application.

31. Your county commissioner:*
    -- Select One --District 1 - John HeinrichDistrict 2 - Julie BraastadDistrict 3 - Jeff ReinertDistrict 4 - Scott SchulteDistrict 5 - Mike GamacheDistrict 6 - Julie JeppsonDistrict 7 - Mandy MeisnerNot Applicable
32. Find your commissioner here:
    MN Pollfinder
34. Personal background:
36. Experience relating to position:*
38. Describe why you are interested in the position:*
40. For more information, contact Brenda Vetter at 763-324-4711 or brenda.vetter@anokacountymn.gov.
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

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