Appointment Information Form - Board of County Commissioners - Seminole County Government

Please type or print the application in black ink and mail to
Chairman, Board of County Commissioners
County Services Building
1101 East First Street
Sanford, FL 32771

NOTE:

A resume or separate sheet with additional information may be included with the application. Please note that you are responsible for updating information on this form. Please call or write the County Commission Office to advise of any changes.

DATE:

____________________

NAME:

____________________________________________________________________________

(Last) (First) (Middle)

ADDRESS:

Home:

______________________________________________________________________

Office:

______________________________________________________________________

PHONE:

Home: ___________________ Office: ___________________ Cell: ___________________

EMAIL:

________________________________________________

EMPLOYER:

___________________________

POSITION:

____________________________ HOW LONG: ________________

EDUCATION:

School Degree(s)

High School

____________________________________________________________________________

College

____________________________________________________________________________

If you currently or have ever held a professional or business license or certificate, please provide the title, issue date and issuing authority. If any disciplinary action has been taken, please state the type and date of the action taken:
_________________________________________________________________________________________

_________________________________________________________________________________________

Please list the Boards or Committees on which you would prefer to be considered for appointment:

_________________________________________________________________________________________

Do you wish to be considered for other Boards? Yes ( ) No ( )

Please state your experience and interests that you feel would qualify you as a candidate for appointment to the Board/Committee(s):

_________________________________________________________________________________________

Florida law requires that members of certain boards file a detailed financial disclosure form. Would you be willing to serve on such a board? Yes ( ) No ( )

Are you a resident of Seminole County?	Yes ( )	No ( )
Are you a registered voter?	Yes ( )	No ( )
Do you own property in Seminole County?	Yes ( )	No ( )
Have you attended Seminole County's Citizens' Academy?	Yes ( )	No ( )
Have you ever served on a County Board?	Yes ( )	No ( )
If yes, when and which board(s)? ______________________________________________

Seminole County strives to ensure that all County Boards are representative of the community. To assist in this endeavor, please check the applicable boxes:

Ethnicity: African American ( ) Caucasian [non-Hispanic] ( ) Hispanic ( ) Other ( )

Gender: Female ( ) Male ( )

Date of Birth: ______________________

REFERENCES:

Name Address Phone

_________________________________________________________________________________________

The Appointment Information Form, when completed and filed with the County Commission Office, is a PUBLIC RECORD under Chapter 119, Florida Statutes, and therefore is open to public inspection by any person.

I understand the responsibilities associated with being a Board member, and I have adequate time to serve on the above Board(s).

___________________________________

Signature