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City of Lakeville 952-985-4400 Application for Appointment to the

Cable TV Board

Please be advised that in accordance with Minnesota Statute, the following information is considered public data: name, city of residence, education and training, and employment history. The private data you provide is needed to identify you and to assist in determining your qualification for appointment. Only authorized employees and appointing authorities have access to the private information submitted. The purpose of the Cable TV Board is to ensure citizen participation in the administration of the City’s cable franchise agreement, to identify present and future needs, and to provide advice to the City Council on the cable franchise agreement, renewals, and administration. The Cable TV Board meets the second Wednesday of each month at 5:45 p.m. Further details on the Cable TV Board can be found in City of Lakeville Resolution No. 11-36.

Please print: Name___________________________________________ Phone_________________  Home /  Cell Address______________________________________ ______________ __________ Street City Zip Code email address:__________________________________________________________ Place of employment__________________________________ Work Phone_______________ (optional)

Have you previously served on any committees to the City Council of Lakeville? If so, please list committee and give the time served. ________________________________________________ year(s) _______________ ________________________________________________ year(s) _______________ Have you served on public boards or commissions in any other cities? If so, please list. ________________________________________________ year(s) _______________ ________________________________________________ year(s) _______________ What is your educational background? High school ____________________________________________________________ College ________________________________________________________________ Trade or vocational ______________________________________________________

Cable TV Board Application How long have you been a resident of Lakeville? _______________________________ What general concerns regarding the use of cable communications in the City of Lakeville do you feel the City should anticipate? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please describe your experience in negotiating or monitoring of contracts such as the cable franchise agreement. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ How can Cable TV Board members stay apprised on changing legislation on local and state levels? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Are you currently involved commercially or employed by cable communications, public or private broadcasting, or the private news media? ______________________________________________________________________ ______________________________________________________________________ Any other comments_____________________________________________________ ______________________________________________________________________

____________________________________ Signature

________________________ Date

Please return this application to: City Clerk, 20195 Holyoke Ave., Lakeville, MN 55044. Copies will be sent to each member of the City Council when there is a vacancy on the Cable Television Board.

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