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2. Pick One*

   I am interested in serving on the following commission (if you have an interest in more than one commission, you may rank your choices)

   1. Planning Commission
   2. Airport Commission
   3. Board of Zoning Adjustments
   4. Economic Development Authority

   1. Comprehensive Plan Action Team
   2. Charter Commission
   3. Recreation and Parks Advisory Committee
   4. Housing and Redevelopment Authority
4. First Name*
5. Last Name*
7. Address1*
9. Address2*
11. City*
12. State
13. Zip
15. Phone Number*
17. Email*
19. Length of residence in Le Sueur (in years)
21. Community, Civic or Volunteer Experience
23. Occupation and Work Experience
25. Educational Background/Training
27. What skills or personal qualities do you possess that would make you valuable as a board or commission member?
29. Why are you interested in volunteering?
31. Membership
    The City Council will not consider applications from regular full-time or part-time Le Sueur employees, or seasonal, temporary, paid-on-call firefighter or contract employee if appointment could cause a conflict of interest.
33. Conflicts of Interest
    No commissioner shall: 1) Enter into any contract with the city unless otherwise authorized by law. 2) Use of their position to secure any special privilege or exemption for themselves or others. 3) Use their office or otherwise act in any manner which would give the appearance of or result in any impropriety or conflict of interest.
35. Background Check*

    The City of Le Sueur will conduct background checks on all new board and commission members. By clicking this checkbox, you are authorizing the City of Le Sueur to complete a background check.

    1. I authorize the City of Le Sueur to complete a background check as part of the board and commission application process.
37. IMPORTANT INFORMATION CONCERNING YOUR APPLICATION
    DATA PRIVACY NOTICE: Minnesota law requires that you be informed of the purposes and intended uses of the information you are providing on this application. Pursuant to Minnesota Statutes Section 13.601, your name, city of residence, employment history, volunteer work, awards and honors are public data and is available to anyone who requests the information. The data that you give us about yourself is also needed to identify you and assist in determining your suitability for the commission(s) for which you are applying. This data is not legally required, but refusal to supply the information requested may affect the City Council’s ability to evaluate your application. Should you be appointed to serve on a board or commission, pursuant to Minnesota Statutes Section 13.601, your residential address and either a telephone number or electronic mail address (or both) where you can be reached also become public information. I have read and understand the data privacy information given above and authorize investigation of all statements contained in this application as may be necessary to arrive at an appointment decision. I certify that all answers given here are true, and I understand that any false information on or omission of information from this application will be cause for rejection of this application.
39. Signature (electronic)*
40. Date
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

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