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2021-02-02 Ex 06Rev. 11-03-2020/JS CITY OF OKEECHOBEE 55 Southeast 3rd Avenue * Okeechobee * Florida * 34974 * (863) 763-3372 APPLICATION FOR CITY CITIZEN BOARD/COMMITTEE APPOINTMENT Please print or type all information. The information from this application will be used by the City Council in considering action on your appointment. The application MUST BE COMPLETED IN FULL. Answer "None" "Not Applicable" or "N/A" where appropriate. CHECK (0) THE BOARD(S) OF INTEREST TO YOU A COPY OF EACH BOARDS DUTIES, MEETING DATES, AND TIMES ARE ATTACHED ❑ Planning Board/Board of Adjustment & Appeals/Design Review Board ❑ Okeechobee Utility Authority Board of Directors (city Residents only) ❑ Police Officers Pension, Firefighters Pension, or General Employees' Retirement System Board of Trustees (City Resident Trustee: 0 OR Fifth Member Trustee: 0 ) ©other: Select Other F1(1,310 pO ('r� I�('.(i on if,cVdi, A( ,"r'Scrc (c2rnrrii.t '- APPLICANT'S FULL NAME: Paulette Bragel NAME COMMONLY USED: RESIDENCE ADDRESS: 909 SW 3rd Avenue, Okeechobee Florida HOW LONG AT ADDRESS: Years: 2 Is this in the City Limits? CI Yes 0 No MAILING ADDRESS: 909 SW 3rd Avenue, Okeechobee Florida TELEPHONE/CELL: 863-610-0010 ARE YOU AN US CITIZEN? 0 Yes 0 No, explain: FLORIDA REGISTERED VOTER? 0 Yes County Registered in: ❑ No EDUCATION: High School Name & Location Year Graduated Palm Beach Gardens High 1970 POST SECONDARY EDUCATION: College Name(s1 Certificate/Degree(s) Awarded Date(s)Attended MILITARY SERVICE: Branch(es) Dates of Service Discharge Date CURRENT OR MOST RECENT EMPLOYER: Self JOB TITLE/DESCRIPTION: Owner/operator, Brown Cow Sweetery WORK ADDRESS: 103 SW Park Street, Okeechobee FL WORK TELEPHONE: 863-357-3357 ° ARE YOU CURRENTLY EMPLOYED AS: (CHECK ✓ ALL THAT APPLY) 0 General Contractor 0 Business Person ❑Architect 0 Engineer 0 Sub -Contractor 0 Realtor ❑ Attorney ❑ Doctor ❑ Surveyor 0 Lay Person 0 Urban Planner ❑ Landscape Architect Have you ever been appointed to, or do you currently serve on, a citizen or community board for any other agency or government? 0 No 0 Yes, and list: AGENCY BOARD NAME POSITION DATE(S) Are you now, or have you ever been, elected or appointed to any public office? 0 No 0 Yes, and list: LEVEL OF GOVERNMENT OFFICE TITLE DATE OF ELECTION TERM(S) Do you work with or have any association with a current member of the board/committee to which you are requesting appointment? 0 No 0 Yes, and list: NAME OF BOARD/COMMITTEE MEMBER(S1 RELATIONSHIP/ASSOCIATION Are you related to, or employed by, any City of Okeechobee employees or elected officials? 0 No 0 Yes, and list: NAME OF EMPLOYEE/ELECTED OFFICIAL RELATIONSHIP/ASSOCIATION Have you ever been found to be in violation of Florida Statutes Chapter 112, Part III, Code of Ethics for Public Officers and Employees? 0 No 0 Yes, and list: DATE(S) NATURE OF VIOLATION Have you ever been convicted of a FELONY, plead guilty or no contest, or entered into an agreement setting forth the terms leading to the reduction or dismissal of the charges? 0 No 0 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. 0 No 0 Yes, and list: JOB TITLE OR COVERED POSITION TITLE RELATIONSHIP Eraa-e_i , {-)0 04- 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. If more space is needed, please attach an additional page. Okeechobee Main Street (Member and Nast Secretary) Okeechobee Chamber of Commerce (Member) Certificate holder in commercial and advertising art 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: 0 MALE 0 FEMALE ETHNIC GROUP: 0 CAUCASIAN 0 BLACK 0 SPANISH HERITAGE 0 NATIVE AMERICAN 0 ASIAN OR PACIFIC ISLANDER 0 OTHER(specify): /ALL THAT APPLY: 0 WARTIME PERIOD VETERAN 0 DISABLED VETERAN ❑ VIETNAM VETERAN HANDICAPPED STATUS: 0 NO 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. 1 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. Signature of Applicant: Date: 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 1 and i1, detention office supervisors, residential officers, residential officer supervisors I and I1, 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 !item; 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 CITY CLERK'S OFFICE USE ONLY APPOINTED TO: CITY COUNCIL MEETING: INITIAL TERM DATES: NOTIFICATION SENT: RE -APPOINTED TERM DATES: RE -APPOINTMENT NOTIFICATION SENT: RESIGNED/TERM SUNSET: CERTIFICATE OF APPRECIATION PRESENTED: Pi!folk, PCi &j r. r.c v. i-u.,-cu cvw., CITY OF OKEECHOBEE 55 Southeast 3rd Avenue * Okeechobee * Florida * 34974 * (863) 763-3372 APPLICATIOItFOR CITY CITIZEN BOARD/COMMITTEE APPOINTMENT Please printor iypraii inforrnalion. The inrurmaiiun rrum this application will he used by the City Council in considering action on your appointment. The application MUST BE COMPLETED IN FULL. Answer "None" "Not Applicable" or "N/A" where appropriate. `Ci11 j ;`�, ,-- .,.cc\\ \ 1.__, ice. CHECK (!) A COPY OF EACH BOARDS 0 Planning Board/Board of Adjustment ❑Okeechobee Utility Authority Board of 0 Police Officers Pension, Firefighters Resident Trustee: & Pension, THE BOARD(S) OF INTEREST TO YOU ' DUTIES, MEETING DATES, AND TIMES ARE AT Appeals/Design Review Board Directors (City Residents Only) or General Employees' Retirement System Board �� . 4�F.1�r7 EDOoo 4. " �C x� -es '"'� N (City p OR Fifth Member Trustee: 0 ) 9 0 Other: Flagler Park Design Review Advisory Committee - s APPLICANT'S FULL NAME: Robert J. Burdge NAME -CO tviI'VMV - U_S-CG V'L --- RESIDENCE ADDRESS: 4204 Birkdale Dr. Fort Pierce, FI 34947 HOW LONG AT ADDRESS: Years: recent Is this in the City Limits? 0 Yes 0 No MAILING ADDRESS: 4204 Birkdale Dr. Fort Pierce, FI 34947 TELEPHONE/CELL: 772-466-0032 (home) ARE YOU AN US CITIZEN? 0 Yes 0 No, explain: FLORIDA REGISTERED VOTER? 0 Yes County Registered in: St. Lucie ❑ No EDUCATION: High School Name & Location Year Graduated Dan McCarty H.S 1968 NUS I SEUUNUAI-tY EUUCA I ION: College Name(sl Certificate/Degreefs) Awarded- ( Aue n5 d Eastern Kenkucky Univ B.A. 1972-74 MILITARY SERVICE; B ichLes [Wog of Ser Ica _ _DischaraeDate None CURRENT OR MOST RECENT EMPLOYER: School Board Of St. Lucie County JOB TITLE/DESCRIPTION: Teacher WORK ADDRESS: Retired after 35.5 years of service WORK TELEPHONE: "ARE YOU CURRENTLY EMPLOYED AS: (CHECK ✓ ALL THAT APPLY) 0 General Contractor 0 Business Person ❑Architect 0 Engineer 0 Sub -Contractor ❑ Realtor ❑ Attorney ❑ Doctor ❑ Surveyor 0 Lay Person 0 Urban Planner 0 Landscape Architect �u (I*, Poi 1 c Have you aver been appointed do you currently serve on, a citizen orcommunity board for any other agency or government? ONo tgYoa.and list: Aoswo, BOARD NAME poamow o»rs(S) City mFort Pierce Planning Board member 2009-c~~rt city "rFurl Pierce Parks committee member 20/9~"rren, city mfort pierce c^","=" 2018="se"/ Are you now, urhave you ever been, elected orappointed &oany public office? []No E]Yes, and list: LEVEL opGOVERNMENT OFFICE TITLE DATE opELECTION rsRw(u} City °/ Fort Pierce c"°m'°./°"", 1988-1996 2=4yea,mrms Do you work with or have any association with a current member of the board/committee to which you are requesting appointment? I0u OYes, and list: NAME orBOARD/COMMITTEE wswasn/s> RsLArmmempmauomAnum Are you related to, or employed by, any City ofOkeechobee employees or elected officials? m/No O Yea. and list: NAME oFEMPLOYE s/E LscrEooppuxAL nEurIOwompmoaom*rmw 14areynuewerbeen found -be in ofEth!ushzrPuh!ioDicara -to -violation -of. � ' and Employees? urw No []Yee. and list: o*rc(S) NATURE upVIOLATION Have you ever been convicted of FELONY, plead guilty or no oonUeat, or entered into an agreement setting forth the terms leading tnthe reduction ordismissal ofthe charges? sa&^o [] Yes, and list: oxTs/S\ vmLxrmw CITY AND STATE ALL /WFQGK8AT!0N PROVIDED ON THIS FORM ISAPUBLIC RECORD. Information for certain individuals with a specific public records exemption can be withheld. In order to claim the exemption complete the following: �; fornncr.-er��� former f:�or law c you o ourron"orfurmor. tho-upe�o*-e�f-:urncn^ or o�or: or :i:i!ian enforcement peroonne|, certified finefighter. Ek4T, paramadic, code enforcement officer, orother covered employee who is exempt from puVlic records disclosure under Florida Statute 119.071? Review list ofother covered employees before �� responding. oWo [] Yes, and list: JOB n`Lson.�ovsnsU,omrION nrLs nsL^rmwax/p .u^mr'm . ,/r �-j /^u.// Describe any skills, expehenoen, 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, If more space mneeded. please attach �additional page. Have worked on r0aUV CQD7nOittSes in Fort Pierce which could help in the development of the park. THE FOLLOWING INFORMATION mUSED WITHOUT REGARD TORACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, DISABILITY, OR MARITAL orxTus 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 woBEARING owYOUR APPOINTMENT: SEX: 12 E El FEMALE ETHNIC GROUP: E§CAUCAS|AN OBLACK OSPAN|SHHERITAGE ONATIVE AMER|CAN [I-AS[ANDRPACIFIC ISLANDER OOTHER(epeuihy): ./ALL THAT APPLY: OWARTIME PERIOD VETERAN ODISABLED VETERAN [3VH[TNA]".1V[T[F6A&,-' HANDICAPPED STATUS.- NO OYES, AND LIST THE HANDICAP: STATEMENT OFAPPLICANT: | certify that the answers are true and complete tothe best ofmyknowledge. }authorize investigation of all statpn`eDts-cpo&ained in this application. | hereby ve|oaeo all companies, _QLQff5D_aE_fMM_g al 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 10request that the City completely and accurately disclose to me the contents of any investigation or reports upon request tothe Office of the City Clerk. | further understand all information provided becomes a matter of public record, CERTIFICATION: | understand that falsificaUon, omiooion, misleading uhsUamanto, or misrepresentation is cause for rejection of this application. | understand that this application is a Public Record and is subject to the provisions of Florida "totuhas Chapter 110. FINANCIAL DISCLOSURE REPORTING: | understand that should | be appointed to a City ofOkeechobee citizen board | am required to complete and file o State of Florida Financial Disclosure Form 1 upon my appointment, annually and a Financial Disclosure Form 1-Final upon myresignation/sunset ofterm. PUBLIC RECORDS/OPEN MEETINGS LAWS: | understand and agree that should | be appointed to a citizen board/committee for the City of Okeechobee, ) will comply with all State Statukao, Florida Administrative Code, and E8oto Constitution regarding public veoonda, naoondu roianUon, public record naqu*oto, and the open public meeting requirements. Signature of Applicant: / / ;a*eread and understand �aohof the above statements. .���/�v��������°� y Date: / 1. The City Code Book Sao. 70'151, 70-171. 78-19170-211 road: ^ membership cfthe board, where possible, shall consist of any of the following: anchiteo, enginear, uunx*yor, urban planner, landscape architect, general contractor, reobor.business person, and lay pocauno.^ 2. Other covered jobs include current or former, their spouse, and children: correctional and correctional probation officers; juvenile probation offioem, aupemieoro, detention superintendents and assistants; Department of Juvenile Justice: detention officers | and ||, detention office eupen/iuom, residential offimens, residential officer supervisors | and ||, counselors and aupen/ioom, human aomioee counselor administrators, senior human aomioea counselor administrators, rehabilitation therapists, and social services counselors; certain personnel of: the Department of Children and Families; the Department qfHealth; 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 mogio1natoa, judges of compensation claims, administrative law judges of the Divisions of Administrative Heohngo, and child support enforcement hearing officers; state attorneys and assistants, statewide prosecutors and assistants; public doh*ndemand assistants, criminal conflict and civil regional counsel and assistants; guardians adlitem�human resource, labor relaUono, or employee natydone directors and aanistanbs, managers orassistant managers of any local government agency or water management district whose duties include hiring and firing ompdoyeoa, labor contract negotiohonu, udmi'/iuhwiiu//� dViiea, iax�uUexio/u, cer,ain i//qnafred 0,eoh,iu/'sy* anJ-conau/iaob; [see #118.U71.Florida Stotuoa]. PLEASE RETURN COMPLETED APPLICATION TO: CITY OFOKEECHO8EE OFFICE OFTHE CITY CLERK 5SSE3noAVENUE, ROOM 18U OKEECHOBEE.FLORIDA 34S74 CITY CLERvOFFICE USE ONLY APPOINTED TO: CITY COUNCIL mEsrws. INITIAL rsnM omso. wor/,n^now sswr. Re'mppu`mrsnrsnm omsn. ne^ppv/wrmpwr NOTIFICATION SENT: nso/swsonenw auwssr. CERTIFICATE OF APPRECIATION PRESENTED: - ---- --- ----- - '----------� | "^ Rev. 11-03-2020/JS CITY OF OKE CHOPEE 55 Southeast 31U Avenue * Okeechobee * Florida * 34974 (863) 763-3372 APPLICATION FOR CITY CITIZEN BOARD/COMMITTEE APPOINTMENT Please print or type all information. The Council in considering action on your FULL. Answer "None" "Not Applicable" or information from this application will be used by the City appointment. The application MUST BE COMPLETED IN 'N/A" where appropriate. CHECK (- ) THE BOARD(S) OF INTEREST TO YOU A COPY OF EACH BOARDS DUTIES, MEETING DATES, AND TIMES ARE ATTACHED ID Planning Board/Board o' Ac,Ls:--e-: i 4:cee s Design Review Board 0 Okeechobee Utility Authicr-:, Eca-i:-ec:ces CTI, Reatonts Orqy) 0 Police Officers Pers:o- F -erc.-:e-F r'e-s c-i, c- General Employees' Retirement System Board of Trustees (City Resident Trustee: 2 OR Fifth Member Trustee: Cl ) CI Other: Flagler Park Des- Re'. e,,,, Advisory Committee El APPLICANT'S FULL "..IME :Margaret J. Cable NAME COMMON:2, -.5E= Magi Cable RES,C"i:N2i= 4 -.° — '7; '': " 5 1852 SW 37th Avenue -..C'T,% _:',.:3 !•"" AC:RES:i • ea .s 42 is this in the City Limits? 0 Yes C3 No MAiL, NG A:D2RESS 1852 SW 37th Ave, Okeechobee, FI 34974 TELEPHONE CELL: 863-610-2662 ARE YOU AN US CITIZEN? 0 Yes :7.3 Nc. explain: FLORIDA REGISTERED VOTER? C) Yes County Registered in: Okeechobee 0 No EDUCATION: ,--gi, s:.-,,., ...a—e & ...xest Year Graduated Okeechobee High School 1972 POST SECONDARY EDUCATION: ;:.,-e,:e Na^-4- s , Peruke) te/Dee ree( sl Awarded Pate() Attended FSU BS 1973-1975 IR5C- AA MILITARY SERVICE: 8-anct-,,es , PISCharge Date N/A CURRENT OR MOST RECENT EMPLOYER: Retired- OCSB JOB TITLE/DESCRIPTION: Retired Science Teacher WORK ADDRESS: N/A WORK TELEPHONE: N/A -1' ARE YOU CURRENTLY EMPLOYED AS: (CHECK / ALL THAT APPLY) 0 General Contractor 0 Business Person 0 Architect 0 Engineer 0 Sub -Contractor C) Realtor 0 Attomey 0 Doctor CI Surveyor 0 Lay Person 0 Urban Planner 0 Landscape Architect 1 014 Have you ever been appointed to, or do you currently serve on, a citizen or community board for any other agency or govemment? 0 No 0 Yes, and list: AGENCY BOARD NAME POSITION DATE(S) City of Okeechobee City Centermiai Com-Cbee Vey -be. 2014-2015 Healthy Start Coalition of Okeechobee Healthy Shirt Ccer-c^ c' Oka -ea -oboe :...-a.--s. 2110-current Our Wino Okeechobee Our %gage OKer,c,:aee V er-be, 2017-zarent Are you now, or have you ever been, elected or appointed tc any public office? 0 No 0 Yes, and list: LEVEL OF GOVERNMENT OFFICE TITLE :A-E. := EL ECITI,Ok1 TERMIS Do you work with or have any association with a current member of the board/committee to which you are requesting appointment? 0 No 0 Yes, and list: NAME OF BOARD/COMMITTEE MEMBERCS1 '-tE .ATIONSH IRASSOCIAT ION Are you related to, or employed by, any City of Okeechobee employees or elected officials? 0 No 0 Yes, and list: NAME Oi: EMPLOYEE ELECTED OFFIC4A1. RELATIONSHIP/ASSOCIATION Have you ever been found to be in violation of Florida Statutes Chapter 112, Part III, Code of Ethics for Public Officers and Employees? 0 No 0 Yes, and list: LATE sl NATURE OF VIOLATION Have you ever been convicted of a FELONY, plead guilty or no contest, or entered into an agreement setting forth the terms leading to the reduction or dismissal of the charges? 0 No 0 Yes, and list: DATECS1 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 swom 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. 0 No 0 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. lf more space Is needed, please attach an additional page. As president of the Okeechobee Historical Society, I feel that I can assist in the planning of the themed parks by providing the historical background neccessary. THE FOLLOWING INFORMATION IS USED WITHOUT REGARD TO RACE, COLOR, REUGION, 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, MINORMES, VETERANS, AND DISABLED PERSONS THAT ARE APPOINTED TO BOARDS. INFORMATION AILL BE USED FOR STATISTICAL PURPOSES ONLY AND HAVE NO BEARING ON YOUR APPOINTMENT: SEX: 0 MALE 0 FEMALE ETHNIC GROUP: 0 CAUCASIAN 0 BLACK 0 SPANISH HERITAGE 0 NATIVE AMERICAN 0 ASIAN OR PACIFIC ISLANDER 0 OTHER(specify): /ALL THAT APPLY: 0 WARTIME PERIOD VETERAN 0 DISABLED VETERAN 0 VIETNAM VETERAN HANDICAPPED STATUS: 21 NO 0 YES, AND LIST THE HANDICAP: STATEMENT OF APPLICANT: | certify that the answers are true and complete to the best of my knowledge. ( 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 informatior. I unders,,and that the City may request a copy of my driver's license. I have the right to request that the City com.pieely and accurateby disclose to me the contents of any investigation or reports upon request to the Office of the City Clerk. I furtre, uicerstanc afi information provided becomes a matter of public CI understand that fa|sification, omission. misleading statements, or misrepresentation is cause for rejection ofthis appUceUon.|understand that this acc�icatonisapubicRecord and is subject Vathe provisions ofFlorida Statutes Chapter 11S. FINANCIAL DISCLOSURE REPORTING: |un�'rsrashould |be appointed uanCity of Okeechobee uifizenboard | am required to complete and file a State of Fbrico Financial Disclosure Form 1 upon my appointment, annually and a Financial Disclosure Form I -Final upon my resignatsn:sunset of term. PUBLIC RECORDS/OPEN MEETINGS LAWS: / undnr fand and agree that should I be appointed to a citizen board/committee for the City of Okeechobee, | .%-i comply*ith all State 8totu<as, Florida Administrative Code, and State Constitution regarding public records. narords retention, public record nequeats, and the open public meeting requirements. I hereby acknowledge that I have read and umt_estanc each of the above statements. Signature ofApplicant: * � Date: /> /0 5- / &-),—; 0 1.The t 70-19170-211 read: ~—mambomhipofthe board, where possible, shall consist ofany �the fo-low�-7g:a��engineer. surveyor, urban planner, landscape architect, general contractor, roa8pr, business person. arc �aypesons.- 2. Other covered lobs include current orhonnectheir spouse, and children: correctional and correctional probation officers; juvenile probation offioors, supemsors. detention superintendents and assistants; Department of Juvenile Justice: detention officers ! and i|, detention office supomiunm, residential officws, residential officer supervisors | and ||, counselors and supeminos, human services counselor administrators, senior human services counselor adminiutra\oxa, rohabi;zotiontherapists, and social services counselors; certain personnel of: the Department ufChildren 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 ofthe Inspector General orinteme/ audit department; justices of the Supreme Court; judges of the district court of appeals, circuit court, and county court; general and special magistrates, judges ofcompensation claims, administrative law judges ofthe Divisions ofAdministrative Hearings, and child support enforcement hearing officers; mhoteattpmeyn and exoiohmnto, statewide prosecutors and assistants; public defenders and assistants, criminal conflict and civil regional counsel and aaoisWnuo;guardians au}itnm;human resource, labor me|adonu, or employee e|mtiuno directors and assistants, managers or assistant managers of any |oom| government agency or water management district whose duties include hiring and firing employees, labor contract nogohotiono, adm)niauation, or other personnel -related duties; tax collectors; certain impaired pmchUones and consultants; [nee B119.071. Florida Statues]. PLEASE RETURN COMPLETED APPLICATION TO: CITY OF OMEECH0BSE OFFICE 55SE 3~AVENUE, ROOM 1U0 OKEECMOBEE,FLORQDA 34974 MY CLERKS OFFICE USE ONLY APP0114Mnu mnCOUNCIL MEETING: wmAL TERM omEo mnpwmION SENT: RE-APpOWED TERM DATES: RE+PPwWwcm °onnCm�wSENT: ��w��� ^v"mET. CERTIFICATE OF APPRECIATION PRESENTED: , ` Rev. 11-03-2020/JS CITY OF OKEECHOBEE 55 Southeast 3rd Avenue * Okeechobee * Florida * 34974 * (863) 763-3372 APPLICATION FOR CITY CITIZEN BOARD/COMMITTEE APPOINTMENT Please print or type all information. The information from this application will s&3 !b p,City Council in considering action on your appointment. The application MUST '. (3"MPL-TED\IN FULL. Answer "None" "Not Applicable" or "N/A" where appropriate. N./ r `\ or,� CHECK (n) A COPY OF EACH BOARDS 0 Planning Board/Board of Adjustment ❑ Okeechobee Utility Authority Board of 0 Police Officers Pension, Firefighters (City Resident Trustee: 0 & Pension, OR jj_ THE BOARD(S) OF INTEREST TO YIDt?ll DUTIES, MEETING DATES, AND TIMES A Appeals/Design Review Board Directors (City Residents Only) or General Employees' Retirement System Fifth Member Trustee: 0 ) r / l ..r NOV i sa. 2O t ,TTACHE C" / /� ; ; Boar ( .u' 0 Other: Flagler Park Design Review Advisory Committee APPLICANT'S FULL NAME: Adam Cohen NAME COMMONLY USED: Adam Cohen RESIDENCE ADDRESS: 3355 SE 44 Avenue, Okee, FL 34974 HOW LONG AT ADDRESS: Years: 2 Is this in the City Limits? 0 Yes 0 No MAILING ADDRESS: 3355 SE 44 Avenue, Okee, FL 34974 TELEPHONE/CELL: 954-682-5532 ARE YOU AN US CITIZEN? 0 Yes 0 No, explain: FLORIDA REGISTERED VOTER? 0 Yes County Registered in: Okeechobee ❑ No EDUCATION: High School Name & Location Year Graduated Coral Springs HS 1993 POST SECONDARY EDUCATION: College Name(s) Certificate/Degree(s) Awarded Date(s) Attended Univ of Florida Masters Accounting 1993 - 1997 MILITARY SERVICE: Branch(esl Dates of Service Discharge Date NONE CURRENT OR MOST RECENT EMPLOYER: Self employed / Colony One On -Line, Inc. JOB TITLE/DESCRIPTION: Executive WORK ADDRESS: Work from home WORK TELEPHONE: 954-341-7031 x 302 ° ARE YOU CURRENTLY EMPLOYED AS: (CHECK ✓ ALL THAT APPLY) ❑ General Contractor 0 Business Person ❑ Architect 0 Engineer 0 Sub -Contractor 0 Realtor ❑ Attorney 0 Doctor 0 Surveyor ❑ Lay Person 0 Urban Planner 0 Landscape Architect {4-1 (,;hen t pc) tc- Have you ever been appointed to, or do you currently serve on, o citizen or community board for any other agency or government? ONo BYes, and list: ^oEnCr eoanowxmE poomow oAre($) Okeechobee County Planing, Review, Appeals wmobo, uo2m'present Are you now, orhave you ever been, elected orappointed toany public office? []No OYes, and list: LEVEL orGOVERNMENT OFFICE TITLE DATE opELECTION rsnw(o) Do you work with or have any association with a current member ofthe board/committee to which you are requesting appointment? []No [] Yes, and list: NAME opoownmoowm/TrscMswosn/a` eemrmwympmuyunmrmw Are you related to, or employed by. any City of Okeechobee employees or elected officials? [] No O Yes,and list: NAME orEMPLOYEE/ELECTED OFFICIAL neuTmwompIAosocmrmw Have you ever been found to be in violation of Florida Statutes Chapter 112. Port ||}. Code of Ethics for Public Officers and Employees? El No OYes, and list: m^rs(S) NATURE OFVIOLATION Have you ever been convicted of FELONY, plead guilty or no contest, or entered into an agreement setting forth the terms leading to the reduction or dismissal of the charges? Q No []Yes. and list: o^re(e) mo/^rmw CITY AND STATE ALL INFORMATION PROVIDED ON THIS FORM IS /\ 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 current orformer, or the child of ou/nerd or former nvm/rn or civilian law enforcement personnel, certified firefighter, EW1T, punsmedic, code enforcement officer, orother covered employee who is exempt from public records disclosure under Florida Statute 119.071? Review list of other covered employees before responding. 0No OYes, and list: JOB TITLE o*COVERED POSITION TITLE ppmr/owox/p 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. If more space is needed, please attach an additional page. Traveled USA extensively with focus on smaller towns. Have gotten perspective from thriving and not doing well towns across USA. Have lived the "coast life" and while appreciate the economic benefits the commercialization can provide, moved to Okeechobee for its small town appeal (white still retaining easy access to more population -dense commercial outlets. Am interested in helping Okeechobee thrive while maintaining its character. Have a formal education in Accounting, spent some time in Law School, and have been self- employed since 1996 in technology and online marketing fields. Understand cost/benefit and limited budget implications and how to get things done with limited resources, work with a diverse set of people, and the challenges inherent in all aspects of running a small business. Diverse exposure. 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: 0 MALE 0 FEMALE ETHNIC GROUP: 0 CAUCASIAN 0 BLACK 0 SPANISH HERITAGE 0 NATIVE AMERICAN ❑ ASIAN OR PACIFIC ISLANDER 0 OTHER(specify): /ALL THAT APPLY: 0 WARTIME PERIOD VETERAN 0 DISABLED VETERAN ❑ VIETNAM VETERAN HANDICAPPED STATUS: 0 NO 0 YES, AND LIST THE HANDICAP: STATEMENT OFAPPLICANT: /certify that the answers are true and complete bothe best cfmyknowledge. /authorize investigation of all statements contained in this application. ! hereby release all cnmponiea, oohools, or persons from all liability for any damage for issuing this information. | understand that the City may request copy of my driver's license. | have the right torequest 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. | further understand all information provided becomes a matter of public record. CERTIFICATION: / understand that falsification, omission, misleading statements, or misrepresentation is cause for rejection o[this application. Iunderstand that this application isaPublic Record and issubject buthe provisions ofFlorida Statutes Chapter 119. FINANCIAL DISCLOSURE REPORTING: / understand that should | beappointed to o City ofOkeechobee citizen board I am required to complete and file oState ofFlorida Financial Disclosure Form 1upon my appointment, annually and Financial Disclosure Form 1 -Final upon my resignation/sunset of term. PUBLIC MEETINGS LAWS: | understand and agree that should I be appointed to a citizen board/committee for the City ofOkeechobee, } will comply with all State Sbatutem, Florida Administrative Code, and State Constitution regarding public roconjm, records rebandon, public record equesto, and the open public meeting requirements. / hereby acknowledge that | have read oW'understa~* -aohofUheabuveotahsmants. Signature ufApplicant: lI—IO-202O 1. The 70-211 read: "....membership of the board, where possible, shall consist of any of the following: archKec, engineer, ounxayor, urban planner, landscape omhd*c, general contractor, realtur.business person, and lay peemna.^ 2, Other covered jobs include current or former, their spouse, and children: correctional and correctional probation officers, - juvenile probation offioem, oypowiouro, detention superintendents and assistants; Department of Juvenile Justice: detention offices | and U. detention office aupemiaora, residential officona, residential uMinar supervisors | and |}, counselors and aupemioono, human services counselor administrators, senior human services counselor administrators, rehabilitation therapists, and social services counselors; certain personnel of: the Department ofChildren 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 orinspectors cfthe Department ofBusiness and Professional Regulation; the Dffica 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 Heahnga, and child support enforcement hearing officers; state attorneys and aooiubsnto, statewide prosecutors and assistants; public defenders and assistants, criminal conflict and civil regional counsel and assistants; guardians ad|hem;human resource, labor ne|atkzny, or employee relations directors and aauistonto, managers or assistant managers of any local government agency or water management district whose duties include hiring and firing ampioyeeo, labor contract negoLietiono, adminiatedon, or other person nel-e|ated duties; tax uo||eoiom; certain impaired practitioners and consultants; [see 0118.871.Florida SXatuas], PLEASE RETURN COMPLETED APPLICATION TO: CITY OFOKEECHQBEE OFFICE OFTHE CITY CLERK 55SE3«oAVENUE, ROOM 1oD OKEECHOBEE.FLORIDA 34974 CITY CLERKS OFFICE USE ONLY APPOINTED TO: CITY COUNCIL msc,ms. INITIAL TERM nmEs. wnnFICxnno vovr RE -APPOINTED TERM o^rsS. nE-^ppomrmcmr NOTIFICATION SENT: nsmwEDncmw ovwopr. CERTIFICATE OF APPRECIATION PRESENTED! ^J°0 ! CITY OF OKEECHQE3 -- 55 Southeast 3rd Avenue * Okeechobee * Florida * 34974 * (863) 763-3372 APPLICATION FOR CITY CITIZEN BOARD/COMMITTEE APPOINTMENT Please print or type all information. The Council in considering action on your appointment. FULL. Answer "None" "Not Applicable" or information from this application will be used by the City The application MUST BE COMPLETED IN "N/A" where appropriate. CHECK (0) THE A COPY OF EACH BOARDS DUTIES, 0 Planning Board/Board of Adjustment & Appeals/Design 0 Okeechobee Utility Authority Board of Directors 0 Police Officers Pension, Firefighters Pension, or (City Resident Trustee: .0 OR Fifth CI Other: Flagler Park Design Review Advisory BOARD(S) OF INTEREST TO YOU MEETING DATES, AND TIMES ARE ATTACHED Review Board (City Residonts Only( General Employees' Retirement System Board of Trustees Member Trustee: 0 Committee APPLICANT'S FULL NAME: Sharie Turgeon NAME COMMONLY USED: Sharie RESIDENCE ADDRESS: 1063 12th St. Okeechobee, FL. 34974 HOW LONG AT ADDRESS: Years: 4+ Is this in the City Limits? 0 Yes CI No MAILING ADDRESS: Same TELEPHONE/CELL: 863-634-7482 ARE YOU AN US CITIZEN? CI Yes 0 No, explain: FLORIDA REGISTERED VOTER? 0 Yes County Registered in: Glades 0 No EDUCATION: Hkm School Name & Location /tar Graduated Northglenn H.S, Colorado 1989 POST SECONDARY EDUCATION: College Narne(S) Certificate/D.1ml( s) Awarded Datets1 Attended N/A MILITARY SERVICE: Branchtes) Dates of Service Discharge Date N/A CURRENT OR MOST RECENT EMPLOYER: Okeechobee County JOB TITLE/DESCRIPTION: Tourism Coordinator WORK ADDRESS: 2800 NW 20th Trail Okeechobee, FL. 34972 WORK TELEPHONE: 863-763-3959 ARE YOU CURRENTLY EMPLOYED AS: (CHECK V ALL THAT APPLY) 0 General Contractor 0 Business Person 0 Architect 0 Engineer 0 Sub -Contractor 0 Realtor 0 Attorney 0 Doctor 0 Surveyor 0 Lay Person 0 Urban Planner 0 Landscape Architect I Have you ever been appointed to, or do you currently serve on, a citizen or community board for any other agency or government? 0 No 0 Yes, and list: AGENCY BOARD NAME POSITION DATE(S) Okeechobee beam Street Okeechobee ldgon Street Board Director At Large September 2020 to present City or Okeechobee _-... .. -Centennial Cotebratien Ad Hoc Cammiitee theta Liasian June 2014- Jume2016 - Are you now, or have you ever been, elected or appointed to any public office? El No 0 Yes, and list: LEVEL OF GOVERNMENT OFFICE TITLE PATE OF ELECTION TERM(S) Do you work with or have any association with a current member of the board/committee to which you are requesting appointment? 0 No ❑ Yes, and list: NAME OF BOARD/COMMITTEE MEMBER($! RELATIONSHIP/ASSOCIATION Are you related to, or employed by, any City of Okeechobee employees or elected officials? 0 No 0 Yes, and list: NAME OF EMPLOYEE/ELECTED OFFICIAL RELATIONSHP/ASSOCIATION Have you ever been found to be in violation of Florida Statutes Chapter 112, Part III, Code of Ethics for Public Officers and Employees? 0 No 0 Yes, and list: DATEf$t Ng7uRE OF VIOLATION Have you ever been convicted of a FELONY, plead guilty or no contest, or entered into an agreement setting forth the terms leading to the reduction or dismissal of the charges? 0 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. CI No 0 Yes, and list: J08 TITLE OR COVERED POBIT1ON 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. 1f more space IS needed. please attach an adddtonal page. Former Executive Director of Main Street which gave me the opportunity to understand the needs of the downtown festivals and events in the parks. Former Executive Director of Main Street where I gave a presentation for park improvements which focused on walkability and pedestrians. Current Board Member of Main Street where we hope to see more public art brought to our community. Being a current County employee that is subject to Public Records, Sunshine as well as reporting to the Board of County Commissioners and the Tourist Development Council Advisory board 1 am prepared to work with a committee that is held to these same standards artd rules. Most importantly is my position as the Tourism Coordinator for Okeechobee. I believe the parks are one of the most valuable assets we have to inspire drive by visitation. By bringing an inviting look to our downtown brings visitors from the main highway to our downtown area. This corridor could be invitation for those that typically would just be driving through to now stopping and spending time in our community. Visitation should be a priority when these improvements are being considered as well as business development and downtown revitalization. Currently tourism's focus is the drive market and now would be the time to take advantage of this trend. 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: 0 MALE 0 FEMALE ETHNIC GROUP: 0 CAUCASIAN 0 BLACK 0 SPANISH HERITAGE 0 NATIVE AMERICAN Ct ASIAN OR PACIFIC ISLANDER 0 OTHER(specify): 'ALL THAT APPLY: 0 WARTIME PERIOD VETERAN 0 DISABLED VETERAN ❑ VIETNAM VETERAN HANDICAPPED STATUS: 0 NO 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 fife a State of Florida Financial Disclosure Form 1 upon my appointment, annually and a Financial Disclosure Fomi 1-Final upon my resignation/sunset of term. PUBLIC RECORDS/OPEN MEETINGS LAWS: I understand and agree that should 1 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. f Signature of Applicant i4-� , � ;, 1 i "" sw _�(17) -. Date 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 deparirnent; 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 CITY CLERKS OFFICE USE ONLY APPOINTED TO: CRY COUNCIL MEETING: INITIAL TERM DATES: NOTIFICATION SENT, RE -APPOINTED TERM DATES, REAPPOINTMENT NOTIFICATION SENT: RESIGNED/TERM SUNSET: CERTIFICATE OF APPRECIATION PRESENTED: