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? IF YES, PLEASE STATE THE NAME(S) OF YOUR RELATIVE(S) AND THEIR POSITION(S) WITH THE CITY:*
 


ARE YOU AWARE OF ANY POTENTIAL CONFLICT OF INTEREST (INCLUDING, WITHOUT LIMITATION, ANY POTENTIAL VOTING CONFLICTS OR POTENTIAL PROHIBITED CONFLICTS) THAT MAY ARISE FROM YOUR SERVING ON THE CITY BOARD OR COMMITTEE TO WHICH YOU ARE SEEKING APPOINTMENT? IF YES, PLEASE EXPLAIN: *
 


DO YOU, ANY MEMBER OF YOUR IMMEDIATE FAMILY, YOUR EMPLOYER OR YOUR BUSINESS (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST) CURRENTLY HAVE ANY CONTRACTUAL RELATIONSHIP WITH, OR DO ANY BUSINESS WITH, THE CITY, OR HAS THERE BEEN ANY SUCH RELATIONSHIP/BUSINESS WITHIN THE PAST 5 YEARS? *
 


DO YOU (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST) HAVE ANY DELINQUENT ACCOUNTS WITH THE CITY OR OWE ANY MONIES TO THE CITY? *
 


DO YOU (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST) HAVE ANY PENDING CODE ENFORCEMENT CASES OR UNPAID, CERTIFIED CODE ENFORCEMENT FINES RELATING TO PROPERTY IN THE CITY THAT IS OWNED OR RENTED BY YOU (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST)? DO YOU (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST) HAVE ANY PENDING CODE ENFORCEMENT CASES OR UNPAID, CERTIFIED CODE ENFORCEMENT FINES FOR ANY OTHER VIOLATIONS RELATING TO OTHER CITY CODES? *
 


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



 

HAS ANY LICENSE, CERTIFICATION, REGISTRATION, OR PERMIT TO PRACTICE ANY REGULATED PROFESSION, OCCUPATION, VOCATION, OR BUSINESS THAT YOU HOLD (OR HAVE HELD) BEEN THE SUBJECT OF AN INVESTIGATION OR COMPLAINT FILED WITHIN THE PAST 5 YEARS, OR IS THERE ANY SUCH INVESTIGATION OR COMPLAINT NOW PENDING? :




HAS ANY LICENSE, CERTIFICATION, REGISTRATION, OR PERMIT TO PRACTICE ANY REGULATED PROFESSION, OCCUPATION, VOCATION, OR BUSINESS THAT YOU HOLD (OR HAVE HELD) BEEN DENIED, REVOKED, ANNULLED, SUSPENDED, RESTRICTED, RELINQUISHED, SURRENDERED, OR OTHERWISE DISCIPLINED WITHIN THE PAST 15 YEARS?






HAVE YOU (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST) BEEN THE SUBJECT OF AN INVESTIGATION OR COMPLAINT FILED WITH A FEDERAL, STATE OR LOCAL AGENCY, LICENSING ENTITY, OR OTHER REGULATORY ORGANIZATION WITHIN THE PAST 5 YEARS, OR IS THERE ANY SUCH INVESTIGATION OR COMPLAINT NOW PENDING?






HAS ANY JUDGMENT OR DECREE OF A COURT BEEN ENTERED AGAINST YOU (OR ANY ENTITY IN WHICH YOU HAVE A CONTROLLING INTEREST) WITHIN THE PAST 15 YEARS RELATED TO A STATE LICENSE, CERTIFICATION, REGISTRATION, OR PERMIT TO PRACTICE ANY REGULATED PROFESSION, OCCUPATION, VOCATION, OR BUSINESS THAT IS REQUIRED FOR YOUR APPOINTMENT OR LISTED ON YOUR APPLICATION, OR IS THERE ANY SUCH CASE OR INVESTIGATION PENDING?




IMPORTANT: PLEASE NOTE THAT THE ABOVE-REQUIRED RESPONSES/DISCLOSURES ARE INTENDED TO ASSIST THE CITY COUNCIL IN CONSIDERING AN APPLICATION FOR APPOINTMENT/RE-APPOINTMENT TO A CITY BOARD OR COMMITTEE, AND WILL NOT RESULT IN THE AUTOMATIC DISQUALIFICATION FROM CONSIDERATION OR APPOINTMENT/RE-APPOINTMENT. THEREFORE, COMPLETE AND ACCURATE RESPONSES SHOULD BE PROVIDED TO THE CITY COUNCIL.


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:



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.

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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.