Citizen Board Application

Contact Information

Name *

First Middle Last

Phone *

Email *

Enter Email Confirm Email

Home address *

Street Address Apartment, suite, unit, building, floor, etc. City State ZIP Code

Business address

Street Address Apartment, suite, unit, building, floor, etc. City State ZIP Code

Your Requested Board(s)

Please list in order of your preference, the board(s) for which you are submitting this application and the special skill(s) that would be beneficial in serving on said board.

Board (First) *

Skills *

Board (Second)

Skills

Board (Third)

Skills

Please read carefully before selecting this board. All information provided will be kept confidential.

Section 760.80, Florida Statutes, states the intent of the Legislature to recognize the importance of balance in the appointment of minority and nonminority persons and persons with physical disabilities to statutorily created decision making and regulatory boards, commissions, councils, and committees.

The Statute requires the City to submit annually the Report of Minority and Physically Disabled Appointments. This report discloses the number of appointments made from each minority and non-minority group and the number of physically disabled persons appointed in the prior calendar year. For this purpose, minority persons are defined as below. In order to comply with this requirement, please select the appropriate options below.

Race *

African American: a person having origins in any of the racial groups of the African Diaspora.
Asian American: a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands, including the Hawaiian Islands prior to 1778.
Hispanic American: a person of Spanish or Portuguese culture with origins in Spain, Portugal, Mexico, South America, Central America, or the Caribbean, regardless of race.
Native American: a person who has origins in any of the Indian Tribes of North America prior to 1835.
Caucasian
Decline to Identify

Gender *

Male
Female
Decline to Identify

Physically disabled? *

Yes
No

Your Details

Are you a registered voter? *

Yes
No

Are you a resident of the city? *

Yes
No

Do you own property in the city? *

Yes
No

Are you employed by the City? *

Yes
No

May we automatically submit your application when vacancies occur? *

Yes
No

Do you have any potential conflicts of interest that may arise from time to time if you serve on one of these boards? *

Yes
No

Please explain *

Are you currently serving on a City board(s)? *

Yes
No

Have you previously served on a City board(s)? *

Yes
No

List any other community involvement

List any work/career experience

List your educational experience

Comments

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Your Requested Board(s)

Please read carefully before selecting this board. All information provided will be kept confidential.

Your Details

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