2. Contact Information
4. First Name*
5. Last Name*
7. Street Address*
9. Address2
11. City*
12. State*
13. Zip*
15. Email*
17. Phone*
18. Type*

    1. Home
    2. Work
    3. Cell
20. Alternate Phone
22. Are you representing an organization?*

    1. Yes
    2. No
23. Name of Organization
27. Employment Information
29. Current Employer
30. Job Title
32. Work Address
34. City
35. State
36. Zip
40. Qualifications
42. Instructions: Please answer the questions below to help us assess your interest on the Multi-Cultural Advisory Committee.
44. 1. If you currently reside or work in Coon Rapids, skip this question and go on to number two below. If you do not reside or work in Coon Rapids, please explain your connection to this city.
46. 2. Please describe the cultural, ethnic, or other group you wish to represent on the Multi-Cultural Advisory Committee.
48. 3. Briefly describe any other qualifications, experience, or other information you believe may be relevant to the position you are seeking.
52. Sign and Submit
54. Government Data Practices Act - Tennessen Warning:*

    Click the box to acknowledge: The data you supply on this form will be used to process this application for which you are applying. You are not legally required to provide this data, but the City will be unable to proceed without it. The data will constitute a public record.

    1. I acknowledge the Government Data Practices Act - Tennessen Warning.
56. Roles and Responsibilities*

    Click the box to acknowledge: I have reviewed what is required of me as a MAC member in the Agreement About Roles and Expectations, and I agree to meet those requirements to the best of my ability.

    1. I acknowledge the roles and responsibilities.
58. Certification*

    Click the box to acknowledge: I certify that all of the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that any false information or omission of information from this application my be cause to remove me from consideration or dismissal if appointed.

    1. I acknowledge this certification.
60. By typing your name below, you certify that all of the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that any false information or omission of information from this application my be cause to remove me from consideration or dismissal if appointed.*
62. Type your email address below to receive a copy of your application. Then, click the "submit" button below, and you will be redirected to a confirmation page.
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field