Please Return To: Anton Jerve

Application for Community Advisory Committee

Please return to: Anton Jerve

1300 City Hall Annex, 25 West 4th Street

Saint Paul, MN 55102

or email to: (preferred method of delivery)

The Minnesota Government Data Practices Act (Minnesota Statutes Chapter 13) governs the City’s use of the information contained in this application. Some of the information sought in this application is private data under the Act. The requested information will be used by the appointing authority to carry out the City’s official appointment responsibilities. You are not required to provide any information. However, failure to answer the application questions may cause the appointing authority to reject your application. The majority of items contained in this application are public, including name, address, employment, skills, training and experience, and are therefore available to anyone requesting it. The remaining items on the application form are classified as private. The private data is available only to you and to other persons in the City, who because of work assignments, reasonable require access to the information.

Name:

Home Address:

Phone: E-mail:

Occupation:

Place of Employment:

Volunteer Commitment(s):

Why are you interested in serving on this Community Advisory Committee?

What skills/trainings or experiences would you bring to the work of the Community Advisory Committee?

Would you identify yourself as representing any of the following? (Check all that apply)

☐ Advocacy organization:______

☐ Artist

☐ Business or professional organization:______

☐ District Council/Neighborhood organization:______

☐ Ethnic/Cultural Community

☐ Major employer

☐ Non-profit organization

☐ Real estate finance and development

☐ Related commission/task force

☐ Small business

☐ Other ______

Please provide two personal references:

Name:

Phone: E-mail:

Name:

Phone: E-mail:

VOLUNTARY DEMOGRAPHIC QUESTIONNAIRE

This form is part of the City’s effort to increase diversity on boards and commission and knowledge of your status will assist us in monitoring the success of our efforts. You are not required to provide the information requested on this form.

How did you hear about this commission?

☐ City of Saint Paul Website ☐ Neighborhood or Community Organization Newsletter

☐ Boards & Commissions Subscribed Email ☐ Personally Invited to Apply

☐ Mayor’s Office Mailing ☐ Other, please explain here

How do you self-identify racially?

☐ White/Caucasian ☐ Hispanic ☐ Black/African-American

☐ Asian or Pacific Islander ☐ American Indian or Alaskan Native ☐ Unknown

☐ Some other race

How do you self-identify? ☐ Male ☐ Female

Are you living with a disability? ☐ Yes ☐ No

Thank you for your participation!