CITY OF BOCA RATON BOARD AND COMMITTEE APPLICATION

NAME:*    HOME ADDRESS:*

CITY:*    ZIP CODE:*

E-MAIL:*    BUSINESS NAME:

OCCUPATION:    BUSINESS ADDRESS:

HOME PHONE:*    BUS. PHONE:

CELL PHONE:


ARE YOU A REGISTERED CITY OF BOCA RATON VOTER?*
HOW LONG HAVE YOU RESIDED IN BOCA RATON?

YEARS:    MONTHS: 

ARE YOU A VENDOR OR EMPLOYED BY A VENDOR OF THE CITY OF BOCA RATON?*

ARE YOU A LOBBYIST OR EMPLOYED BY A LOBBYIST AS DEFINED IN THE PALM BEACH COUNTY LOBBYIST REGISTRATION ORDINANCE?*

HAVE YOU ATTENDED ANY BOCA RATON CITY COUNCIL OR ADVISORY BOARD MEETINGS?*
    

HAVE YOU BEEN CONVICTED OF A FELONY?*
 


DO YOU HAVE ANY CRIMINAL CHARGES PENDING?*
 


DO YOU HAVE ANY RELATIVES EMPLOYED BY THE CITY?*
 


ARE YOU AWARE OF ANY POTENTIAL CONFLICT OF INTEREST THAT MAY ARISE FROM YOUR SERVING ON THIS CITY BOARD OR COMMITTEE?*
 


DOES YOUR BUSINESS OR YOUR EMPLOYER HAVE ANY CONTRACTUAL RELATIONSHIP WITH, OR DO ANY BUSINESS WITH THE CITY?*
 


DO YOU HAVE ANY DELINQUENT ACCOUNTS WITH THE CITY OR OWE ANY MONIES TO THE CITY?*
 


DO YOU HAVE ANY PENDING CODE VIOLATIONS RELATING TO PROPERTY OWNED OR RENTED BY YOU IN THE CITY (OR ANY OTHER VIOLATIONS RELATING TO OTHER CITY CODES?*
 


HAVE YOU EVER BEEN FOUND TO HAVE VIOLATED THE FLORIDA CODE OF ETHICS FOR PUBLIC OFFICERS AND EMPLOYEES, PALM BEACH COUNTY CODE OF ETHICS (OR ANY OTHER ETHICS CODE)? *



 


BACKGROUND INFORMATION REGARDING LICENSURE / CERTIFICATION (IF APPLICABLE):

HAS ANY LICENSE, REGISTRATION, OR PERMIT TO PRACTICE ANY REGULATED PROFESSION, OCCUPATION, VOCATION, OR BUSINESS REQUIRED FOR YOUR APPOINTMENT OR LISTED ON YOUR APPLICATION BEEN DENIED, REVOKED, ANNULLED, SUSPENDED, RELINQUISHED, SURRENDERED, OR OTHERWISE DISCIPLINED WITHIN THE PAST 15 YEARS, OR IS ANY SUCH PROCEEDING OR INVESTIGATION NOW PENDING? :



HAS ANY JUDGMENT OR DECREE OF A COURT BEEN ENTERED AGAINST YOU WITHIN THE PAST 15 YEARS RELATED TO THE STATE LICENSE OR CERTIFICATION THAT IS REQUIRED FOR YOUR APPOINTMENT OR LISTED ON YOUR APPLICATION, OR IS THERE ANY SUCH CASE OR INVESTIGATION PENDING?



NOTE: IT IS THE PREFERENCE OF THE CITY COUNCIL THAT APPLICANTS ATTEND AT LEAST ONE MEETING OF THE BOARD(S) TO WHICH THEY ARE SEEKING APPOINTMENT.

I hereby apply for appointment to the following board(s):



















*Members of these boards are required to comply with Florida Statutes regarding filing a Statement of Financial Interests.

Briefly describe why you wish to serve as a member of the board(s) or committee(s) and how your personal experience and background relate to the function of the board(s) or committee(s) on which you wish to serve:


EDUCATIONAL BACKGROUND:
University attended:

Degrees received:

Major area of study:


List community/civic involvement:


PROFESSIONAL BACKGROUND: (Please complete, if any of the criteria listed below is applicable to membership qualifications for a board for which you have made application)







Type of Business:




ARE YOU REGISTERED IN THE STATE OF FLORIDA? *

ARE YOU LICENSED IN THE STATE OF FLORIDA? *

DO YOU HOLD A CERTIFICATE OF COMPETENCY? *

DO YOU POSSESS A CITY OF BOCA RATON OCCUPATIONAL LICENSE? *

HOW LONG HAVE YOU PRACTICED THE ABOVE PROFESSION? *

Board interviews are conducted at City Council Workshop and Regular Meetings, which are generally held the 2nd and 4th Mondays and 2nd and 4th Tuesdays, respectively, of each month. Workshop Meetings begin following the conclusion of the Community Redevelopment Agency meeting that is scheduled to begin at 1:30 p.m. and Regular Meetings commence at 6:00 p.m. in the City Hall Council Chamber. Applicants are notified of vacancies and interview dates prior to the scheduled interview. Applications are kept on file in the City Clerk's Office for a period of one year. Applicants may supplement their application with a resume or other information relevant to their qualifications.

.

Select your resume: (Resume cannot exceed 2MB file size.)
 



TERMS OF ACCEPTANCE

Declaration of Personal Information Exemption

Personal information provided in this application is public information unless the applicant qualifies for an exemption pursuant to Florida Statutes. You are encouraged to thoroughly read the applicable sub-sections of F.S. 119.071. If you qualify for an exemption, please indicate below which statutory provision you are citing for the exemption. If you qualify, your address and phone number are protected information. You may contact the Board Coordinator at 393-7743 if you have any questions.

My address and telephone number are statutorily exempted from public disclosure, pursuant to Section  of Florida Statutes.

Signature

I understand the duties and responsibilities of the board(s) or committee(s) for which I am applying. By signing below, I warrant the truthfulness and accuracy of the information provided in this application, including that applicable to any personal information exemptions.



Signature of Applicant:*
                                               Please type your First and Last Name
Date:*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.