2022 08 02 Item 04. B., Exhibit 02EXnIbIt Z
8/2/2022
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CITY OF OKEECHOBEE _ V- B
55 Southeast 31d Avenue, Okeechobee, Florida 34974 Phone: (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 when considering action on your appointment. The application MUST BE COMPLETED IN
FULL. Answer "None" "Not Applicable" or "N/A" where appropriate. 2 3 4 s s
P RECEIVED .,P
CHECK THE BOARD(S) OF INTEREST TO YOU
A COPY OF EACH BOARD'S DUTIES, MEETING DATES, AND TIMES AREA _ CH
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Planning Board/Board of Adjustment & Appeals/Design Review Board �11� L
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❑Okeechobee Utility Authority Board of Directors (city Resraents onto) a
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❑ Police Officers' Pension, Firefighters' Pension, or General Employees' Retirement System Board Tyr v�d
(City Resident Trustee: OR Fifth Member Trustee: _...._. _..._)
❑ Other:
APPLICANT'S FULL NAME:
NAME COMMONLY USED:
RESIDENCE ADDRESS:
HOW LONG AT ADDRESS:
Years: 1 lL_ Is this in the City Limits? A Yes ❑ No
MAILING ADDRESS:
G46 W014 e
TELEPHONE/CELL:
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EMAIL:
P� 41 F17
ARE YOU A US CITIZEN?
® Yes ❑ No, explain:
FLORIDA REGISTERED VOTER?
es County in:
0 -
❑ No7
EDUCATION:
Hi ,�.c,hoot Na�mes) &moo—atio(s Year Graduated
`� a%ife-4 -yc*Y :�.J 1,9101
College NamCertificate/Degree(s) Awarded Date(s) Atlended
POST SECONDARY EDUCATION:t//��p�
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9
MILITARY SERVICE:
Branch s Dates of Service Discharge Date(s)
CURRENT OR MOST RECENT EMPLOYER:
JOB TITLE/DESCRIPTION:
WORK ADDRESS:
oG1-4 w/1�9 J �
WORK TELEPHONE:
Page 1 of 5 Last Name/& First Initial A6;, * C __.
ARE YOU CURRENTLY EMPLOYED AS:
(CHECK ALL THAT APPLY)
0 General Contractor
❑ Engineer
❑ Attorney
❑ Lay Person
❑ Business Person
0 Sub -Contractor
❑ Doctor
0 Urban Planner
0 Architect
❑ Realtor
❑ Surveyor
0 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? [! No ❑ Yes% and list: V you are currently serving on another Board that the State deems an 'offlce,11 your
application cannot be considered. Each Board will have to be reviewed and verified.
AGENCY BOARD NAME POSITION DATE(S)
Are you now, or have you ever been, elected or appointed to any public office? r No ❑ 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? W1 No ❑ Yes, and list:
NAME OF BOARD/COMMITTEE MEMBER
k5l RELATIONSHIP/ASSOCIATI I
Are you related to, or employed by, any City of Okeechobee employees or elected officials? IN No ❑ 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? Ile No ❑ 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 ❑ Yes, and list:
DATES VIOLATION CITY AND STATE
Page 2 of 5 Last Name & First Initial C
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 ❑ 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 m e space is needed, please attach an a W nal age.
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Pape 3 of 5 Last Name & First Initial ��j z�- — _.
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: f MALE 0 FEMALE
ETHNIC GROUP: I CAUCASIAN ❑ BLACK ❑ SPANISH HERITAGE 0 NATIVE AMERICAN
0 ASIAN OR PACIFIC ISLANDER 0 OTHER (specify):
CHECK ALL THAT APPLY: 0 WARTIME PERIOD VETERAN ❑ DISABLED VETERAN 0 VIETNAM VETERAN Ald
HANDICAPPED STATUS: # 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 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
Date:t2A42-64*,
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 Statutes].
Page 4 of 5 Last Name & First Initial 4
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
Boards Applicant is appointed to:
#1 _ -- —_.---
#2
#3
Verified State's consideration as an "Office":
#1_-. -_.-.. --
#2
#3
APPOINTED TO:
CITY COUNCIL
MEETING:
INITIAL TERM
DATES:
NOTIFICATION
SENT:
RE -APPOINTED TERM
DATES:
RE -APPOINTMENT
NOTIFICATION SENT:
RESIGNEDITERM
SUNSET:
I CERTIFICATE OF
APPRECIATION PRESENTED:
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I
Paqe 5 of 5 Last Name & First Initial