Contact Information

REQUEST FOR BOARD APPOINTMENT FORM

Contact Information

First Name

Last Name

Middle Name

Email Address

Cell Phone Number

Are you a Registered Voter?

Yes

Home Address

Home Address cont'd

City

State

Zip Code

Mailing Address

Mailing Address cont'd

City

State

Zip Code

Advisory Board of Interest (Select up to 3 boards)

Interest #1

Interest #2

Interest #3

NOTE: You are not required to answer demographic questions. However, they are asked in order that the boards, commissions and authorities to which the Board of County Commissioners makes appointments may be representative of the citizens of Seminole County.

Are you of Hispanic origin?

Yes

Gender

Disabled?

Yes

Race

Place of Employment

Job Title

Education

School Name:

Please answer for your highest level of education

Degree Received

Reference 1

Name

Phone Number

Relationship

Reference 2

Name

Phone Number

Relationship

Reference 3

Name

Phone Number

Relationship

Please briefly state your experience, interests, or elements of your personal history that you think qualify you for appointment to the board(s) you have chosen.

Provide relevant qualifications and experience (max 500 words).

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). I also understand that Florida law requires members of certain boards file a detailed financial disclosure form.

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