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2024 11 04 Item 3 Election of Adam Crum as 6th MemberCITY OF OKEECHOBEE 55 Southeast 3rd 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. CHECK THE BOARD(S) OF INTEREST TO YOU A COPY OF EACH BOARD'S DUTIES, MEETING DATES, AND TIMES ARE ATTACHED D Planning Board/Board of Adjustment & Appeals/Design Review Board D Okeechobee Utility Authority Board of Directors (city Residents Only) 1 Police Officers' and Firefighters' Pension, or General Employees' Retirement System Board of Trustees (City Resident Trustee: OR Fifth Member Trustee: io 1 D Other: APPLICANT'S FULL NAME: t lit ti �" NAME COMMONLY USED:1r,\ RESIDENCE ADDRESS: HOW LONG AT ADDRESS: Years: Is this in the City Limits? D Yes ❑ No MAILING ADDRESS: i� " 'S ' _ nd Ave 'Iw kee 3 q7y TELEPHONE/CELL: ;� -, EMAIL: ��{(';Lll�1L��C�E ChCC�il1 ARE YOU A US CITIZEN? )(Y -es D No, explain: FLORIDA REGISTERED VOTER? Yes County Registered in: D No EDUCATION: High School Name(s) & Location(s) Year Graduated ry College Nanne(s) Certificate/Degree(s) Awarded Date(s) Attended POST SECONDARY EDUCATION:%c MILITARY SERVICE: Branch(es) Dates of Service Discharge Date(s) CURRENT OR MOST RECENT EMPLOYER: ,l JOB TITLE/DESCRIPTION: WORK ADDRESS: j( WORK TELEPHONE: Page 1 of 5 Last Name & First Initial I u,y6-\ /-/ ARE YOU CURRENTLY EMPLOYED AS: ❑ General Contractor ❑ Business Person ❑ Architect (CHECK ALL THAT APPLY) ❑ Engineer ❑ Sub -Contractor ❑ Realtor ❑ Attorney ❑ Doctor ❑ Surveyor ❑ Lay Person ❑ Urban Planner I 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: *If you are currently serving on another Board that the State deems an "office," your application cannot be considered. Each Board will have to be reviewed and verified. AGENCY BOARD NAME) POSITION DATE(S) -1. i Are you now, or have you ever been, elected or appointed to any public office? kNo ❑ 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? ❑ 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? kNo ❑ 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? "o ❑ 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? q, No Li Yes, and list: DATES VIOLATION CITY AND STATE Page 2 of 5 Last Name & First Initia 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 l: +.,; i i; l �'� l� �Lu l'���f +t�4 �.,1•i�i_ t J�i� / ��t'-,S�Sc lam) 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. ff more space is needed, please attach an additional page. Page 3 of 5 Last Name & First Initial 1�s�•-�2 A 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: C, .MALE ❑ FEMALE ETHNIC GROUP: GI CAUCASIAN ❑ BLACK ❑ SPANISH HERITAGE ❑ NATIVE AMERICAN ❑ ASIAN OR PACIFIC ISLANDER ❑ OTHER (specify): CHECK ALL THAT APPLY: ❑ WARTIME PERIOD VETERAN ❑ DISABLED VETERAN ❑ VIETNAM VETERAN HANDICAPPED STATUS: '(NO ❑ 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 tread and 'derstand each of the above statements. p �� (%