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<br />08/17/05 WED 11:00 FAX 701 241 5728 <br /> <br />CASS COUNTY COURTHOUSE <br /> <br />141002 <br /> <br />APPLICATION FOR BOARDS AND COMMISSIONS <br /> <br />FOR OfFICE USE ONLY <br />Appointed To <br /> <br /> <br />Oate <br /> <br />YOUR NAME (la~t.First.Middle) <br />o;..dc. <br />Permanent Mailing Addres~ <br />~ 4 J/'ol/e.. A _ $E <br />Present Mailing Address (It different) <br /> <br />legislatjvl~Di~trict Number <br /> <br />s <br /> <br /> <br />State <br />AI <br /> <br /> <br />City <br /> <br />State Zip Code <br /> <br />Your Occupation - Title <br />.$pci l ~eS ~A-...A..,- <br /> <br />Business Phone No. <br />741-;;' s') (J <br /> <br />Residence Phone No. . I <br />:J.i.z -2()/Y- <br /> <br />Emplo er Name ... 1 l <br />e. ~l ~ <br /> <br />c5 c.J..~J)'3~' 'c i <br /> <br /> <br />Zip Code <br />S-go7 I <br /> <br />Em'ployer Address <br />Bc>,- JI. g <br />EDUCAIION AND GENERAL QUALIFICATIONS <br /> <br />lEVEL NAME OF SCHOOL LOCA liON No. Years Did YOII Major Course(s) <br />Attended Graduat,~ 1 of Study . <br />High School J'JJ.a ",Ic~ lh~1I'J/~ 1"- Y <br />College 11 AID ~,.;",d f?wJ<.,$ ~ 'Y f ~':.~~' <br />TradelB usinesslCorrrespondence <br />Memberships in <br />Organizations <br />and Offices Held_ <br />Indicate Dates Held <br />: I <br />Volunt~er Activities <br />Indicate if Past or Present <br />Your Special Skills and <br />Qualifications <br /> <br />REFERENCES (list three persons, not related to you, ......hom you have known for at least one year.) <br /> <br />NAME <br /> <br />ADDRESS <br /> <br />PHONE NO. <br /> <br />Ye.ars <br />Acquainted <br /> <br /> <br />tJ'D S8071 <br /> <br />N-O '01 t <br /> <br />ell." /II]) <br />$80/::1- <br />I certify that the facts contained in this application are true and correct to the best of my knowledge. I authorize investiga- <br />tion of all statements contained herein and the references listed above to give you any and all inform~tjon concerning my <br />qualifications and any pertinent information they may have, personal or otherwise, and release all parties from all liability <br />fo~amages that may result from furnishing the same to you_ , <br /> <br />I ~ I (am not) at least eighteel"! ~lB) years of age. <br /> <br />RETURN COMPLETED FORM TO: <br />Cass County Commission <br />Box 2806 <br />Fargo, ND 58108 <br /> <br />Bg)(- II". g ~e~ e,' <br />I3D)t.. I' B "jO,u,;;~ (!/ <br />t*a.-L &S!2~ <br /> <br /> <br />,7 q -'JS7tJ <br />7'1 'i -.;1. 7rJ <br />3i7- ~3Sz- <br /> <br />.32..- <br />...3~ <br />/0 <br /> <br />SIGNATURE <br /> <br />~ ~duJ <br />~-/~ -0 ~ <br /> <br />DATE <br /> <br />(Please attach a copy of your resume') <br /> <br />.~,' .1 ~.. ~:. _ _ <br />