Jorgenson, Nancy J - Council at Large FORM 11(REVISED 1980)MILLER-DAVIS CO.,MINNEAPOLIS
AFFIDAVIT=0F CANDIDATE & RECEIPT FAR. AILING
TOWN OR CITY ELECTIONS
State o�nnesota fr a No.
County of o�
(Print name as wanted on ballot)
swear(or affirm)that I am qualified under the Constitution and Laws of the United States and State of Minne-
sota to seek the elective public office indicated below. I am a qualified voter in the subdivision where I seek
election. I will be 21 years of age or more on assuming office. I will be a resident of my election district for at
least 30 days by election day. I have not filed.for any other office at this election.
I am seeking election to the-office ofd
I reside in the city or township of
My post office address is: 7sc) - E
cQ (Zip) 65.5 &Z
(SigViiard as wanted on ballot)
Subscribed and oWprn to before me this M-*41 day of 19y'2
( own ,(C'ty)Clerk— otary Public
County,Minn.
NOMINATION PETITION
We, the undersigned, registered voters of the City of Fridley,
hereby nominateNQn vu 6RQ,ensurl , whose residence is
P l �� S� h •�.' J�,2,'c A- , W ti. s S�3 P-
5130 , for the office of
dLA to be voted for at
the election to be held on the ��U - day of Z 19
and we individually certify that we are registered voters and that we
have not signed more nomination petitions of candidates for this office
than there are persons to be elected thereto.
NAM STREET AND NQVQ R
s5 8-Z/2A6k-4�
/V0,4C.., J jok teh'son , being duly sworn, deposes and says, "I
(Nime of Circulator)
am the circulator of the foregoing petition paper containing signatures,
and that the signatures appended thereto were made in my presence and are
the genuine signatures of the persons whose names they purport to be."
I wish my nametoappear on the ballot exactly as follows:
/VQn J Jo�2 e*iso/i
('Please Print)
(fgwur f e)
Subs ibec and sworn to before ` s /�da
OfMesa
c$;azie 1'ee
NOTARY PUBLIC-MINNESOTA
ANOKA COUNly
(NOtary Public) :j!:ymy commission sxpiras 4.15.94
This petition, if found insufficient by the City Clerk, shall be returned
to ��a n4,M , at Number 57,3 0 /�(,/,C S1• A)-F Street.
I hereby indicate my willingness to accept the office of
+440eif duly elected thereto.
01#kurof )
3/0/1/9
* Tt�mTON PETITION
we, the undersigned, registered voters of the City of Fridley,
hereby nominate Q J �5a� , whose residence is
S730 101k �� ,��.P,u , AU , for the office of
to be voted for at
the election to be held on the z _day of o 0 • , 19 f 9 ;
and we individually certify that we are registered voters and that we
have not signed more nomination petitions of candidates for this office
than there are persons to be elected thereto.
STREET AND NLWBM
121 ct
-CX&AIL- IeMtt NE
op-
23
a490
Z
art J Joh eh son , being duly sworn, deposes and says, "I
( of Circulator)
am the circulator of the foregoing petition paper containing signatures,
and that the signatures appended thereto were made in my presence and are
the genuine signatures of the persons whose names they purport to be."
I wish my name to appear on the ballot exactly as follows:
J JOA ensal1
(Please Print)
44-4 j
(fg0tu#f o "nee)
Subsc d d orn to before M /L'�'da
of _ r .t!A'sr,
es�azte Tee e4��U
rA�NNESOf♦
ANOKA COUNTY
(Notary Public) t '°^ My commission expires 416•�N
This petition, if found insufficient by the City Clerk, shall be returned
to /VQn -, J R Jen SdA , at Number 5730 ��� c�?�A-) Street.
I hereby indicate my willingness to accept the office of
AReA4,ex-- ' ��,��- if duly elected thereto.
X I
44� 6e - I
( i tur of )
3/0/1/9
CITY Of FRIDLEY
PUBLIC DISCLDISURE STATEKENr BY CITY COUNCIL OR 0OUNCIL
NAME / Q '--106 21"1013 DATE �� Q
TO: CITY CLERK
In conformance with Sec. 5 . 04 of the City Code, I hereby make the following
declarations regarding my financial and personal interests:
1. Names of all business corporations, partnerships, other business
enterprises, or governmental agencies doing business with the City of
Fridley or located within the City of Fridley:
a. with which I have a financial interest.
(As used in Chapter 5 , the term financial interest shall be deemed
to include ownership of more than 10% of: The outstanding stock in
a corporation, an interest in a partnership, proprietorship, or
other business entity, or an interest in real property. Financial
interest shall apply to real or personal properties owned by the
person making the disclosure and by said person's spouse.)
b. With which I have a personal interest.
(As used in Chapter 5 , the term personal interest shall be deemed
to apply whenever a person required to make a disclosure under this
code of ethics shall be associated with a business as an employee,
officer, director, trustee, partner, advisor or consultant.)
NAME OF BUSINESS FINANCIAL PERSONAL
PA//R'IIM2S1H I P, ETC. ADDRESS INTEREST INTEREST
(Use additional paper if necessary.)
2. A list of the non-homestead real property located within the City of
Fridley in which I currently have a financial interest:
NON-HOMESTEAD REAL PROPERTY ADDRESS
NI
(Use additional paper if necessary.)
1 y • •
3. A list of the non-homestead real property located within the City of
Fridley in which I had a financial interest within the preceding three
(3) years:
NON-HOMESTEAD REAL PROPERTY ADDRESS
(Use additional paper if necessary.)
4. A list of the names and nature of business of all corporations,
partnerships, or other business enterprises with which I have a
financial interest and in which I know one or more other persons covered
by this code of ethics also having a financial interest in said
enterprise. (This list shall indicate the name or names of such persons
or persons having such interest in said enterprise.)
NAWRE OF BUSINESS - OF ALL CORPORATIONS
NAMES PARTNERSHIPS, OR OTHER BUSINESS ENTT2PRISES
1✓/,Q
(Use additional paper if necessary.)
I do swear (or affirm) that this report is a full and true statement
pursuant to Sec. 5. 04 of the City Code.
(Si t e)
Mote: This statement must be filed annually or when there is a material
change in financial interest or in position held.