HomeMy WebLinkAboutA Bergen Application 2000PLEASE COMPLETE BOTH- SIDES OF APPLICATION FORM.
CITY OF CAPE CANAVE
L, FLORIDA
APPLICATION TO SERVE ON CITY BOARD
Applicant Name: 771-7-(--/e"/A— Home Telephone: — (
Home Address: e' 2 '7 /42 5 /2 6,4--
Business:
Office Address:
Brief Description of Education and Experience:
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m/4 s
7- I
Are you a registered voter? Yes z---v No
Business Telephone:
Have you been a resident of the City for 12 months or longer? Yes /7 No
Do you currently hold a public office? Yes No
Are you presently employed by the City? Yes No tv
At the present time, do you serve on a City Board? Yes No i.----
At the present time, do any of the following relatives of yours serve on the City Council: father, mother, son, daughter,
brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, grandparent, grandchild, father-in-law, mother-in-
law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother,
stepsister, half brother or half sister?
Yes No /
At the present time, do any of the following relatives of yours serve on any other City board, commission or special
district: spouse, parent, child, grandparent or sibling of the whole or half blood?
Yes No /
Please specify which City Board you are interested in serving on:
(Indicate Preference, 1st, 2nd, 3rd, etc.)
Beautification Board Construction Board of Adjustment & Appeals*
Board of Adjustment* Library Board
Business and Cultural Development Board Planning and Zoning Board*
Code Enforcement Board* i/ Recreation Board
Community Appearance Board*
*Members of these Boards are required to complete Financial Disclosure Forms upon appointment to said Board and prior to July 15th of each year
following the initial appointment while still a member of said Board.
City of Cape Canaveral, Florida
City Board Application.
Page 2
Please list what you feel are your qualifications to serve as a member on one of the City's Boards:
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/3
Would you consider serving on another City Board other than the one(s) you have selected on the front of this form?
Yes
Applicant's signature:
PLEASE NOTE: 1 Initial appointment to any City Board is subject to Ciry Council approval following a brief
interview before the City Council at a regularly scheduled meeting.
Date: / 2 -
2. Your application will remain effective for one year from the date of completion,
3 If you should have any questions regarding the completion of this application, please
contact the City Clerk's Office at 868-1221.
PLEASE RE' U
CAPE CANAVE
COMPLETED APPLICATION TO THE CITY CLE
CITY £LL, 105 POLK AVE CAPE CANAVE
'S Ork CE,
L, FL 32920