Laserfiche WebLink
Conflict of Interest is defined as the participation in any activity, recommended action, <br />or decision from which the individual has or could have the potential to receive personal <br />gain, whether it is direct or indirect. In accordance with this definition, do you have any <br />legal or equitable interest in any business which could be construed as a conflict of <br />interest? Yes X No <br />If yes, provide details on a separate piece of paper. <br />John R. Derksen (electronic signature) 24 May 2013 <br />Applicant Signature Date <br />Questions may be directed to the City Clerk's office at 218-568-5222. <br />Return Completed Application to <br />City of Pequot Lakes <br />City Clerk <br />4638 County Road 11 <br />Pequot Lakes, MN 56472 <br />E:mail: s eine ,pequotlakes-mn°gov <br />Website: www.pequotlakes-mn.gov <br />�Thi,r cq�/�/i�•udint� i�'ill hc' kc'j�l on 1%!c fur' ��i�c' t'ec��/': i�Jie/• lhut lirnc' c� r�c'rr cr�/�li�•ulior� nn.�s[ h� Ji/c'e% <br />OFFICE USE O1VLY <br />The Applicant is: <br />Council Action: <br />Notes: � �i <br />New Applicant <br />� Not Appointed <br />_ Appointed to: <br />Date Appointed: <br />Term Expires: _ <br />_ r� . _ - <br />Applying for Reappointment <br />�Z °— d � �- /� � <br />C:\Documents and Settings\speine�I,ocal Settings\Temporary Internet Files\OLKF7�Application Form P Z 5-24-13.doc <br />Page 3 <br />