Seminole County

Appointment Information Form

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                         



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