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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: speine(a�pequotlakes-mn.�ov <br />Website: www.peQuotlakes-mn.�ov <br />T/�is up/��lic�u�ioi� ri;ill hc• kc/�� ��n /il�' /��r ��i��� rc�ru•: �r/tcr [/�ut Jime u n��i�i�� �����nlirutr��n rnus! he fi/c�cl. <br />OFFICE USE ONLY <br />The Applicant is: <br />Council Action: <br />New Applicant <br />� Not Appointed <br />Appointed to: <br />Date Appointed: <br />Term Expires: <br />Applying for Reappointment <br />Ivotes: lC.,�.� ��—, j �2� _ " `% r.� `— l � °' �l�` � ,�iE'!�, <br />�,�-�' %?cr�,^ ' <br />C:\Documents and Settingslspeine�I,oca1 Settings\Temporary Intemet Files\OLKF7\Application Form P Z 5-24-13.doc <br />Page 3 <br />