Fillable Application For Senate Board And Commission Appointments (The Florida Senate)

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Application For Senate Board And Commission Appointments (The Florida Senate)

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The Application For Senate Board And Commission Appointments (The Florida Senate) form is 9 pages long and contains:

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  • 11 check-boxes
  • 165 other fields

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File type: PDF

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Board and Commission Application
for Appointments by the
President of the Florida Senate
Page 1 of 8
Instructions for Submitting the Application for
Senate Board and Commission Appointments
Complete this form in its entirety and return to the Office of the Senate President.
This
form may be completed online* and submitted electronically to OfficeoftheSenatePresident@flsenate.gov
.
This f
orm may be completed online, printed, faxed to (850) 487-5087, or mailed to:
Office of the Senate President
Attn: Board and Commission Appointments
Suite 409 Capitol
404 South Monroe Street
Tallahassee, FL 32399-1100
Co
ntact the President’s office at (850) 487-5229 with any questions or concerns.
*If you fill out the Application online and want to keep an electronic copy on your computer, use the “Save As” command under the
“File” menu, and save the document to your hard drive. If you close the document without saving, your information will be lost.
W
Page 2 of 8
APPLICATION FOR SENATE BOARD AND COMMISSION APPOINTMENTS
https://www.flsenate.gov/Offices/President/Appointments
1.
Board(s) of Interest:
Personal Information
2.
Name:
Dr./Mr./Mrs./Ms. First Middle/Maiden Last Suffix (Jr./Sr./III/etc.)
Nickname/Preferred Name
3.
Have you ever been known by any other name? Yes No
If yes, give your other name(s) and explain:
4.
Spouse’s Name:
5.
Email Address:
6.
Provide the address you prefer correspondence, regarding this application, be sent:
_______________________________________________________________________________________________________________________________
7.
Your Gender: Male Female Prefer not to disclose
8.
Describe yourself within one or more of the categories below. This information is requested pursuant to Section
760.80, Florida Statutes. Access the Statute online
.
Prefer not to disclose
Caucasian
“African-American”
“Hispanic-American”
“Asian American”
“Native-American”
“American woman”
“physically disabled”
Page 3 of 8
9.
Birth Date: Birth Place:
Month/Day/Year City State Country
10.
As of what date have you been a continuous resident of Florida?
Month/Day/Year
11.
Are you a U.S. Citizen? Yes No
If you are a naturalized citizen, give the date of naturalization:
Month/Day/Year
12.
Are you registered to vote in Florida? Yes No
County of Registration Party Affiliation _________________________________________________________
13.
Are you or have you ever been a member of the armed forces of the United States? Yes No
Dates of Service: Branch or Component: ________________________________________________
Date and Type of Discharge:
_
Did you serve in combat? Yes No
Cont
act Information
14.
Residence:
Street
City
County
Post Office Box
City
County
Telephone: (area code) number
Mobile: (area code) number
15.
Business:
Business Name
Street
City
County
Zip Code
Post Office Box
City
County
Zip Code
Telephone: (area code) number
FAX: (area code) number
Page 4 of 8
Employment
16.
Provide the requested information for your current and all employers within the last 5 years:
A.
Employer Address
Type of Business Occupation/Job Title Dates of Employment
B.
C.
D.
E.
Education
17.
High School:
Name City State
18.
Postsecondary Institutions:
Name and Location Dates Attended Certificate/Degree Earned
Employer
Address
Type of Business
Occupation/Job Title
Dates of Employment
Employer
Address
Type of Business
Occupation/Job Title
Dates of Employment
Employer
Address
Type of Business
Occupation/Job Title
Dates of Employment
Employer
Address
Type of Business
Occupation/Job Title
Dates of Employment
Page 5 of 8
Special Qualifications
19.
List any of your special qualifications you consider relevant to being appointed to a board, commission, council,
or
committee, including any type of licensure or certification you hold, including any civic, professional, or political
organizations to which you belong.
Type or Name of License or Certificate Number Granting Agency Date Granted
Name of Civic, Professional, or Political Organization Office(s) Held Membership Start Date
20.
Give any additional information you consider relevant to your appointment to a board, commission, council, or
committee.
Ethical Disclosure
21.
If required by law or administrative rule, will you file financial disclosure statements? Yes No
22.
Have you been a registered lobbyist, or have you lobbied, at any level of government at any time during the
past
four years? Yes No
If yes, other than reimbursements for expenses, please provide:
Agency Lobbied Principal(s) Represented Date(s) Compensation Received
23.
Have you or any business with which you are or have been affiliated as an owner, officer, or employee ever held any
contractual dealings during the last four years with any state, district, or local governmental agency in Florida?
Yes No
If yes, please provide:
Business Name Your Relationship to Business Agency Business’s Relationship to Agency
Page 6 of 8
24.
Have members of your immediate family [spouse, child, parent(s), sibling(s)] or businesses of which members of
your immediate family have been owners, officers, or employees, held any contractual or other direct dealings
during the last four years with any state, district, or local governmental agency in Florida?
Yes
No
If yes, please provide:
Business Name Family Member’s Relationship to You Family Member’s Relationship to Business Agency Business’s Relationship to Agency
25.
Has probable cause ever been found that you were in violation of Part III, Chapter 12, Florida Statutes, or the Code
of Ethics for Public Officers and Employees? Yes No
If yes, please provide:
Date Nature of Violation Disposition
26.
Have you ever been suspended from any office by the Governor of the State of Florida? Yes No
If yes, please provide:
Title of Office Date of Suspension Reason for Suspension Result (Reinstated/Removed)
27.
Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law or
ordinance? (Exclude traffic violations for which a fine of $150 or less was paid.) Yes No
If yes, please provide:
Date Place Nature of Violation Disposition
28.
Have you ever been refused a fidelity, surety, performance, or other bond?
Yes
No
If yes, please provide:
Type of Bond Insurer of Bond Date Reason(s) Given
29.
Do you know of any reason why you would not be able to attend fully to the duties of the office or position to which
you may be appointed? Yes No
If yes, please explain:
Page 7 of 8
Public Service
30.
Are you currently or have you ever been elected to any public office in Florida? Yes No
If yes, please provide:
Office Title Date of Election Term of Office Level of Government
31.
Have you ever been appointed to any public office in Florida? Yes No
If yes, please provide:
Office Title Date of Appointment Term of Office Level of Government
32.
If your services was on an appointed board, commission, council, or committee, how frequently were meetings
scheduled?
If you missed any regularly scheduled meetings, please provide:
Number of Meetings Attended Number of Meetings Missed Reason for Absence(s)
33.
Have you previously been appointed to any office that required confirmation by the Florida Senate? Yes No
If yes, please provide:
Title of Office Term of Appointment Result of Confirmation
34.
Have you ever been employed by any state, district, or local governmental agency in Florida? Yes No
If yes, please provide:
Position Employing Agency Dates of Employment
Page 8 of 8
References
35.
List three persons who have known you well within the past five years and provide the requested information on
each person. Exclude relatives and Members of the Florida Legislature.
A.
Name Address
Telephone: (area code) number
B.
Name Address
Telephone: (area code) number
C.
Name Address
Telephone: (area code) number
Authorization and Certification
I authorize the Office of the Senate President to verify all information contained in this application and I
acknowledge that pursuant to Senate policy my application is subject to review by the public in
accordance with Art. 1, s. 24 of the Florida Constitution.
Prior to my appointment by the Senate President, I agree to voluntarily submit my Social Security number
(SSN)
and driver’s license number (DLN) to the Office of the Senate President for the sole purpose of
conducting a background investigation relating to my appointment. I acknowledge that if I provide my
SSN and DLN, they will remain confidential and exempt from disclosure, except for the purposes stated
herein or as provided by law. I understand that my failure to provide my SSN or DLN may preclude my
appointment.
I certify that the above statements are true and complete to the best of my knowledge. I further
understand that any misrepresentations or false statements made by me on this application, or any
supplement hereto, may be grounds for immediate discharge and/or rejection from consideration for
further appointments.
______________________________________________ _____________________
Applicant’s Signature Date
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Application For Senate Board And Commission Appointments (The Florida Senate)

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Completed 20 July 2020

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