Open Appointments Application for Carver County Community Development Agency Board At-Large, Public Housing Commissioner

The Carver County Community Development Agency (CDA), through the federally funded Public Housing program, is required to have one-member of its Board be a participant of those programs. The At-Large Board member will participate in CDA Board actions related only to the Public Housing program. All household members ages 18+ living in CDA owned Public Housing (scattered site units or Spruce Apartments) are eligible to apply.

Part 1: Applicant Information

Applicant Name:

Last Name First Name M.I.

Home Address:

Street Address


☐ Mr. ☐ Mrs. ☐ Ms.

Email Address:

Part 2: Your Rights as a Subject of Data/Applicant Declaration

Pursuant to Minnesota Statutes Chapter 13, Carver County CDA informs you that the following information which you are asked to provide in this application is private data: telephone numbers, fax number, residential street address, email address, business/financial interest, status as recipient of human services, and criminal record. Unless and until you are appointed to the CDA Board, this information will be available only to you, the County and CDA officials and staff who need it to perform their job duties. Furnishing this information is voluntary. Failure to provide the information requested in Parts 2-4 of this application may disqualify you from appointment to the CDA Board. The remainder of the information in this application is public.

State law requires your residential street address and either your email address or telephone number be made public if you are appointed to the CDA Board. Unless you indicate otherwise, Carver County CDA will make your email address public. If you do not have an email address, your home telephone number will become public. You may request that both be made public or that your business telephone number instead of your home telephone number be made public.

If appointed, I request that Carver County CDA make public (check all that apply):

☐ Email Address ☐ Home Telephone Number ☐ Business Telephone Number

Signature of Applicant Date

Part 3: Per Diems

The At-Large appointee to the Carver County Community Development Agency Board will receive $55 per diem, mileage and $25 internet reimbursement (per month) for attendance at regular and special meetings. Applicants may choose to decline the per diem at the time of application.

Please check this box if you wish to decline the per diem: ☐ Decline

Part 4: Statement of Qualifications

Describe your interest in serving on the Carver County Community Development Agency Board and any background, knowledge and skills which you possess that will be of value to the Board.

THANK YOU!

Return completed form by May 31, 2017 to:

Carver County CDA

Attention: Allison Streich

705 N. Walnut Street

Chaska, MN 55318

Email:

Fax: (952) 448-6506

Office Use Only
Date Received: / Appointment Date:
Date Entered: / Term Ended Date:
Appointed:
/ £ Yes £ No / Retention Date:
Committee: