2021-01-19 Ex 0155 Southeast 3"' Avenue * Okeechobee * Florida * 34974 * (863Y 7V3-3372
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APPLICATION FOR CITY CITIZEN BOARDICOMMITTEE APP,
Please print or type all information. The information from this application will be us h
Council in considering action on your appointment. The application MUST BE COMkWgINT
FULL. Answer "None" "Not Applicable" or "NIA" where appropriate.
CHECK (0) THE BOARD(S) OF INTEREST TO YOU
A COPY OF EACH BOARDS DUTIES, MEETING DATES, AND TIMES ARE ATTACHED
Q Planning Board/Board of Adjustment & Appeals/Design Review Board
n Okeechobee Utility Authority Board of Directors (City Residents Only)
Q Police Officers Pension, lFireflgl� Pension, or General Employees' Retirement System Board of Trustees ts
(City Resident Trustee: tl OR Fifth MeT,ber Trustee:
Other: 3;S7 M QJ0 0 e e, 10a A,2 ;'o kt--
APPLICANT'S FULL NAME:
NAME COMMONLY USED:
RESIDENCE ADDRESS:
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HOW LONG AT ADDRESS:
Years: Is this in the City Limits? OIXes Q No
MAILING ADDRESS:
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TELEPHONE/CELL:
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ARE YOU AN US CITIZEN?
WYe Q No, explain:
FLORIDA REGISTERED VOTER?
es County Registered in:
Q No
EDUCATION:
High School Name & Location Year Graduated
0c, P 0 IJ
POST SECONDARY EDUCATION:
College Name(s) Certificate/Degree(s) Awarded Date(s) Attended
MILITARY SERVICE:
Branch(es) Dates of Service Discharge Date
CURRENT OR MOST RECENT EMPLOYER:
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JOB TITLE/DESCRIPTION:
WORK ADDRESS:
WORK TELEPHONE:
ARE YOU CURRENTLY EMPLOYED AS:
13 General Contractor C) Business Person U Architect
(CHECKV ALL THAT APPLY)
0 Engineer U Sub -Contractor 0 Realtor
IJ Attorney Q Doctor U Surveyor
Q Lay Person 13 Urban Planner Q Landscape Architect
Have you ever been appointed , or do you currently serve on, a citizen or community board for any other agency or
government? ❑ No 1A Yes, and list:
AGENCY BOARD NAME POSITION 1 DATE(S)
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Are you now, or have you ever been, elected or appointed to any public office? ®No ❑ Yes, and list:
LEVEL OF GOVERNMENT OFFICE TITLE DATE OF ELECTION TERM(S)
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Do you work with or �ave any association with a current member of the board/committee to which you are requesting
appointment? Oi No ❑ Yes, and list:
NAME OF BOARD/COMMITTEE MEMBER(S) RELATIONSHIP/ASSOCIATION
Are you related to, or employed by, any City of Okeechobee employees or elected officials? GNo a Yes, and
list:
NAME OF EMPLOYEE/ELECTED OFFICIAL RELATIONSHIP/ASSOCIATION
Have you ever been fou%od to be in violation of Florida Statutes Chapter 112, Part III, Code of Ethics for Public Officers
and Employees? Q No ❑ Yes, and list:
DATE(S) NATURE OF VIOLATION
Have you ever been convicted of a FELONY, plead guilty or no c ntest, or entered into an agreement setting forth the
terms leading to the reduction or dismissal of the charges? No ❑ Yes, and list:
DATE(S) VIOLATION CITY AND STATE
ALL INFORMATION PROVIDED ON THIS FORM IS A PUBLIC RECORD. Information for certain individuals with
a specific public records exemption can be withheld. In order to claim the exemption complete the following:
Are you a current or former, the spouse of a current or former, or the child of a current or former sworn or civilian law
enforcement personnel, certified firefighter, EMT, paramedic, code enforcement officer, or other covered employee who
is exempt from public records disclosure under Florida Statute 119.071? Review list of other covered employees before
responding. SNo ❑ Yes, and list:
JOB TITLE OR COVERED POSITION TITLE RELATIONSHIP
Describe any skills, experiences, interests and/or background information about yourself that would be helpful to the
Board you wish to serve on. Include personal accomplishments that qualify you for the appointment.
It more space is needed, please attach an additional page.
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THE FOLLOWING INFORMATION IS USED WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, DISABILITY, OR MARITAL
STATUS. HOWEVER, THE FEDERAL AND STATE GOVERNMENTS REQUIRE THE CITY TO PROVIDE STATISTICS ON THE NUMBER OF WOMEN, MINORITIES,
VETERANS, AND DISABLED PERSONS THAT ARE APPOINTED TO BOARDS. INFORMATION WILL BE USED FOR STATISTICAL PURPOSES ONLY AND HAVE
NO BEARING ON YOUR APPOINTMENT:
SEX: D MALE 0 FEMALE
ETHNIC GROUP: @ CAUCASIAN ❑ BLACK ❑ SPANISH HERITAGE ❑ NATIVE AMERICAN
❑ ASIAN OR PACIFIC ISLANDER ❑ OTHER(specify):
./ALL THAT APPLY: ❑ WARTIME PERIOD VETERAN ❑ DISABLED VETERAN
❑ VIETNAM VETERAN
HANDICAPPED STATUS: /O 0 YES, AND LIST THE HANDICAP:
STATEMENT OF APPLICANT: I certify that the answers are true and complete to the best of my knowledge. I authorize
investigation of all statements contained in this application. I hereby release all companies, schools, or persons from all
liability for any damage for issuing this information. I understand that the City may request a copy of my driver's license. I
have the right to request that the City completely and accurately disclose to me the contents of any investigation or reports
upon request to the Office of the City Clerk. I further understand all information provided becomes a matter of public
record.
CERTIFICATION: I understand that falsification, omission, misleading statements, or misrepresentation is cause for
rejection of this application. I understand that this application is a Public Record and is subject to the provisions of Florida
Statutes Chapter 119.
FINANCIAL DISCLOSURE REPORTING: I understand that should I be appointed to a City of Okeechobee citizen board I
am required to complete and file a State of Florida Financial Disclosure Form 1 upon my appointment, annually and a
Financial Disclosure Form 1-Final upon my resignation/sunset of term.
PUBLIC RECORDS/OPEN MEETINGS LAWS: I understand and agree that should I be appointed to a citizen
board/committee for the City of Okeechobee, I will comply with all State Statutes, Florida Administrative Code, and State
Constitution regarding public records, records retention, public record requests, and the open public meeting
requirements.
I hereby acknowledge that I have read and understand each of the above statements.
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Signature of Applican 4r 617 Date: _01-10r7 202,I
1. The City Code Book Sec. 70-151, 70-171, 70-19170-211 read: ....membership of the board, where possible, shall
consist of any of the following: architect, engineer, surveyor, urban planner, landscape architect, general contractor,
realtor, business person, and lay persons."
2. Other covered jobs include current or former, their spouse, and children: correctional and correctional probation officers;
juvenile probation officers, supervisors, detention superintendents and assistants; Department of Juvenile Justice:
detention officers I and II, detention office supervisors, residential officers, residential officer supervisors I and II,
counselors and supervisors, human services counselor administrators, senior human services counselor administrators,
rehabilitation therapists, and social services counselors; certain personnel of: the Department of Children and Families; the
Department of Health; the Department of Financial Services; and the Department of Revenue or local governments whose
responsibilities include revenue collection and enforcement or child support enforcement; investigators or inspectors of the
Department of Business and Professional Regulation; the Office of the Inspector General or internal audit department;
justices of the Supreme Court; judges of the district court of appeals, circuit court, and county court; general and special
magistrates, judges of compensation claims, administrative law judges of the Divisions of Administrative Hearings, and
child support enforcement hearing officers; state attorneys and assistants, statewide prosecutors and assistants; public
defenders and assistants, criminal conflict and civil regional counsel and assistants; guardians ad litem; human resource,
labor relations, or employee relations directors and assistants, managers or assistant managers of any local government
agency or water management district whose duties include hiring and firing employees, labor contract negotiations,
administration, or other personnel -related duties; tax collectors; certain impaired practitioners and consultants; [see
§119.071, Florida Statues].
PLEASE RETURN COMPLETED APPLICATION TO:
CITY OF OKEECHOBEE
OFFICE OF THE CITY CLERK
55 SE 3RD AVENUE, ROOM 100
OKEECHOBEE, FLORIDA 34974