Application for service on MPCA

Environmental Justice Advisory Group

Environmental Justice Program
Doc Type: Advisory Board

The Environmental Justice Advisory Group will advise the Minnesota Pollution Control Agency (MPCA) Commissioner on MPCA’s
work to integrate the environmental justice principles of fair treatment and meaningful involvement into its work, provide feedback on
its effectiveness, and offer suggestions for future improvements. For more information, visit https://www.pca.state.mn.us/ej.
By request, this application will be made available in alternative format (Braille, large print, audio tape, etc.).
How to apply: Please complete this form and submit by mail or email by August 12, 2019, to:
Attn: José Luis Villaseñor
Minnesota Pollution Control Agency
520 Lafayette Road North
St. Paul, MN 55155-4194
Email: joseluis.villasenor@state.mn.us
Questions: Contact MPCA Environmental Justice Coordinator José Luis Villaseñor at 651-757-2575 or by email at
joseluis.villasenor@state.mn.us.

Applicant information (Please read the statement at the end of this form before completing the application.)

First name: Last name:

Mailing address:
City: State: Zip code:
Phone: Email:

Tell us about yourself

Please explain why you would like to serve on the advisory group. Describe your background and the experience, skills, or perspectives
you would bring to this group that would help the MPCA ensure that all Minnesotans benefit from our work. Please limit your response to
300 words (approximately). Feel free to include or attach additional information if necessary.

Optional applicant information

In order to intentionally create a diverse committee, we are requesting the following information. Providing this information is
optional. You may provide answers to all, some, or none of these questions.
Gender: Disability:
Age: Race/Cultrure/Ethnicity:
Some of the information you are being asked to provide on this application is considered by state law (Minn. Stat. § 13.43) to be
private (such as personal contact/optional applicant information). You are being asked to provide this information to assist the MPCA
in contacting you regarding your possible participation in the agency’s Environmental Justice Advisory Group and to learn more
about you as a potential group member. You are not required to provide any of the requested information. The MPCA will use the
information provided to learn more about you and to contact you regarding this service opportunity. If this information is not provided,
it will be difficult for the MPCA to contact you and learn more about you. The private information that you provide will be available
only to MPCA staff who will be reviewing applications and other entities/persons authorized by law or court order.

https://www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats
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