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Contact Information

REQUEST FOR BOARD APPOINTMENT FORM

Contact Information

First Name

Cell Phone Number

Middle Initial

Office Phone Number

Last Name

Home Phone Number

Email Address

Home Address

Address 1

Address 2

City

State

Zip Code

Work/Office Address

Address 1

Address 2

City

State

Zip Code

Employment Information

Employer

Position

How Long

Education

High School

College

Degree Received

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:

Board Interest

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

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

Do you wish to be considered for other Boards?

Florida law requires that members of certain boards file a detailed financial disclosure form. Would you be willing to serve on such a board?

Tell Us About Yourself

Are you a resident of Seminole County?

Are you a registered voter?

Do you own property in Seminole County?

Have you ever served on a County Board?

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

If yes, when and which boards(s)?

Ethnicity

Gender

Date Of Birth

Reference 1

Name

Address

Phone Number

Reference 2

Name

Address

Phone Number

Reference 3

Name

Address

Phone Number

Certification

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).