HomeMy WebLinkAboutKellum ApplicationRECEIVED BY
CITY OF CAPE CANAVERAL
FINANCE DEPT
DATE: aaAP Lpq
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CITY OF CAPE CANAVERAL
R APPOINTMENT TO CITY ADVISORY BOARD OR COMMITTEE
Pursuant to Section 2-17i, Cape Canaveral Code
City Code requires prospective and existing board members to fill out an application. City Code also
prohibits a person from serving on a City Board or Committee if that person has been convicted of a
felony, unless their civil rights have been restored.
AUG 2 2 2014
Please complete the following in the space provided:
A. GENE CC
1. Applicant Name: rn Rt M VV_U Ct. lin C rnc'e
2, Home Address: get 10 CO r,in Aaae...... earmtlefed.
3. Home and Cellular Telephone: .17Crq ell 1-3 - ga-d e7
4. Occupation: ti. Oar_ rv1/4) 10 t 3
5. Business Telephone: riq5-SOIS
6. Business Address: 105- Lb ReikPoin't FAA cp oerafi--
7. E-Mail: rrun eelitun 61) 14o-falai(' ColY1
B. ELIGIBILITY
The information provided in this section is for purposes of determining whether you are eligible to
serve on a City advisory board or committee.
1. Are you duly registered to vote in Brevard County? (Y) \71 (N)
2. Have you been a resident of the City of Cape
Canaveral for 12 months or longer? (Y) \ (N)
3a. Are you a Business owner: (Y) (N)
3b. If yes to 3a, please list the name:
4a. Have you ever been convicted or found guilty, regardless
of adjudication, or a felony in any jurisdiction? Any plea
of nolo contendere (no contest) shall be considered a
conviction for purposes of this question. (Y) (N) *)(
4b. If yes to 4a, have your civil rights been restored? (Y) (N)
5a. Do you presently serve on any other City of Cape
Canaveral advisory board or committee? (Y) (N)
5b. If yes to 5a, please list each:
Page 1 of 3
6. City ordinance requires that all persons applying for a
City advisory board or committee must voluntarily consent
to a standard criminal background check before being
appointed to a board or committee. Do you voluntarily
consent to having a standard background check
performed on you by the City of Cape Canaveral?
7a. Are you related to a City of Cape Canaveral Council
member by blood, adoption, or marriage?
7b. If yes to 7a, please provide name(s) of person(s) and relationship to you:
C. INTERESTS!EXPERIENCE
initials
(Y) (N)
(Y) (N)
1. Briefly state your interest in serving on a City advisory board or committee:
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2. In numerical sequence (1 = most interested), please rank which advisory board or committee
on which you wish to serve:
a. Board of Adjustment*
b. 3 Business and Economic Development Board*
c. Code Enforcement Board*
d. 9, Community Appearance Board*
e. Construction Board of Adjustment and Appeals*
f. Culture and Leisure Services Board
g. Library Board
h. Planning and Zoning Board*
Other:
*Members of these boards are required to complete and file with the supervisor of Elections a
Financial Disclosure Form upon appointment to said board and prior to July 1 of each year following
the initial appointment while still a member of said board.
3. Briefly state any prior experiences in serving on any governmental board or committee:
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4. Please list any specialized skills and training (e.g., architect, engineer, general contractor, etc.)
that you feel help to qualify you for membership on the desired board or committee.
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D. STATE REPORTING REQUIREMENTS
Section 760.80, Florida Statutes, requires that the City annually submit a report to the Secretary of
State disclosing race, gender, and physical disabilities of board and committee members. Please
check the appropriate boxes:
Page 2 of 3
RACE
African -American
Asian -American
Hispanic -American
Native -American
Caucasian
Not Known
GENDER
DISABILITY
Male
Female
Not Known
Physically disabled
YOU HEREBY REPRESENT TO THE CITY OF CAPE CANAVERAL, UNDER PENALTY OF
PERJURY, THAT THE INFORMATION PROVIDED HEREIN IS TRUE AND ACCURATE TO THE
BEST OF YOUR KNOWLEDGE, AND THE CITY OF CAPE CANAVERAL HAS THE RIGHT TO
RELY ON THAT INFORMATION,
YOU HEREBY ACKNOWLEDGE THE EXISTENCE OF THE CODE OF ETHICS FOR PUBLIC
OFFICERS [SECTIONS 112.311-326, FLORIDA STATUTES] AND THE FLORIDA "SUNSHINE
LAW" [SECTION 286.011, FLORIDA STATUTES], WHICH MAY PERTAIN TO YOU IF YOU ARE
APPOINTED TO A CITY ADVISORY BOARD OR COMMITTEE, AND IF APPOINTED, IT IS YOUR
SOLE OBLIGATION AND DUTY TO COMPLY WITH SUCH LAWS.
PLEASE NOTE:
• Appointment to any City board is subject to City Council approval following a brief interview
before the City Council at a regularly scheduled meeting.
• Your application will remain effective for one year from date of completion.
• If you should have any questions regarding the completion of this application, please contact
the City Clerk's Office at (321) 868-1220 ext. 221.
Signature:
Please return to:
City of Cape Canaveral
Office of the City Clerk
105 Polk Avenue
Cape Canaveral Florida 32920
For Office Use Only:
Date application received:
Date Appointed:
Appointed by:
Board Appointed to:
Term Expires:
Page 3 of 3
Date: 9/ZZIIN
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