HomeMy WebLinkAboutJarvis ApplicationCITY OE CAPE CANAVERAL
APPLICATION FOR APPOINTMENT TO CITY ADVISORY BOARD OR COMMITTEE
Pursuant to Section 2-171, 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.
Please complete the following in the space provided:
A. GENERAL
1. Applicant Name: -57-EP,r../E-__,ciJA z
ZL a 6‘
2.
Home Address: W'ci L.-/ PLIJ-72•7i) DC-7 2 67(AP e C. A ,1,1-7644
3. Home Telephone: 31( - 7 / 3 .2
4. Occupation: 7- / c 7-rive
5. Business Telephone: 3 5-1 K5---
6. Business Address:
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) X (N)
2. Have you been a resident of the City of Cape
Canaveral for 12 months or longer? (N)
3a. Have you ever been convicted or found guilty, regardless
of adjudication, of a felony in any jurisdiction? Any plea
of nolo contendere (no contest) shall be considered a
conviction for purposes of this question.
3bIf yes to 3a, have your civil rights been restored?
4a. Do you presently serve on any other City of Cape
Canaveral advisory board or committee?
4b. If yes to 4a, please list each:
(N) X
,ee
CITY OF CAPE CANAVERAL
APPLICATION FOR APPOINTMENT TO CITY ADVISORY BOARD OR COMMITTEE
Pursuant to Section 2-171, 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.
Please complete the following in the space provided:
A. GENERAL
1. Applicant Name: 5-7Z---)(2,67E,A._.) JA R._ v,
cy' C)
2. Horne Address: 6_, I 171,/,Tk777) Do 2,, DI2i (APc CA,,u A J,-=-)e±/41-
3. Home Telephone: 3at - - 7 / 3 2
4. Occupation: T TT/. \-% 3T7Z c 7-6:e
5. Business Telephone: 3 - 6-, I -
6. Business Address:
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'?
2. Have you been a resident of the City of Cape
Canaveral for 12 months or longer?
3a. Have you ever been convicted or found guilty, regardless
of adjudication, of a felony in any jurisdiction? Any plea
of nolo contendere (no contest) shall be considered a
conviction for purposes of this question.
(Y) (N)
(Y) (N)
3b. If yes to 3a, have your civil rights been restored? (Y) (N)
4a. Do you presently serve on any other City of Cape
Canaveral advisory board or committee?
4b. If yes to 4a, please list each:
(Y) (N) X
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:
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 PENALTIES 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:
▪ Initial 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 the date of completion.
9 If you should have any questions regarding the completion of this application, please
contact the City Clerk's at(1) 868-1221.
Signature:
Date:
Please return to:
City of Cape Canaveral
Office of the City Clerk
105 Polk Avenue
Cape Canaveral, Florida 32920