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Application for Appointment to Public Health Advisory Committee

Complete this online application to be considered for appointment. Applications will be review by board staff. The City Council and Mayor approve all appointees.

Information provided on fields with this icon is public according to the Minnesota Data Practices Act. Any information you provide in these fields may be made available to the public.

You are applying for
Seat#
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Membership Requirements
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{{applicationSeat.TermStartDate | date : common.constants.DATE_FORMATE}} {{applicationSeat.TermEndDate | date : common.constants.DATE_FORMATE}} {{applicationSeat.MembershipNote}}

Please use the name you wish us to use on paperwork and public documents; it does not need to be your legal name if you go by a different chosen name.

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Information provided here is open to the public per The Minnesota Data Practices Act Applicant Details
Information provided here is open to the public as per The Minnesota Data Practices Act

Please enter first name.

Please enter last name.

Please enter address.

Please enter city.

Please select state.

Please enter only digits.

Please enter Minimum 5 characters.

Please enter no more then 10 characters.

Please enter postal code.

Please select ward.

Please enter phone.

Please enter valid phone number.

Please enter valid email address.

Please enter email address.

Employer Information

Please enter employer name.

Please enter occupation.

Please enter employer address.

Please enter city.

Please enter state.

Please enter postal code.

Please enter only digits.

Please enter minimum 5 characters.

Please enter no more then 10 characters.

Please enter work phone.

Please enter valid phone number.

Note: If appointed, Minnesota statute 13.601 requires that a telephone number and/or an email address where the appointee can be reached and residential address will be considered public data.

Please select public contact preference.


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References: List names, addresses and telephone numbers of no more than 3 references

Please enter name.

Please enter address.

Please enter phone.

Please enter valid phone number.



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If you need help with this information, please This link open a new windowcontact 311.
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