Fill - Free fillable Board Appointments Application V1 PDF form

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The information from this questionnaire will be used by the Governor’s office and, where

applicable, The Florida Senate in considering action on your confirmation. The

questionnaire MUST BE COMPLETED IN FULL. Answer “none” or “not applicable”

where appropriate. Please type or print in black ink.

Date Completed

Name:_______________________________________________________________________________________________

MR./MRS./MS./DR. FIRST LAST MIDDLE/MAIDEN

Section 1- General Information

List all your places of residence for the last ten (10) years.

Address City & State Dates: From / To

__________________________________________________________ __________________

List all your former and current residences outside of Florida that you have maintained at any time during

adulthood

Address City & State Dates: From / To

__________________________________________________________ __________________

Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal

law, regulation, or ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less

was paid.) Yes ___ No ___

If “Yes” give details:

Date Place Nature Disposition

______________________________________________________________________________

Appointments Questionnaire

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Section 2- Education and Background

High School: _____________________________________ Year Graduated: _____________

(Name) (Location)

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List all postsecondary education institutions attended:

Name Dates Degree Received

______________________________________________________________________________

Are you or have you ever been a member of the armed forces of the United States? Yes ___ No___

If “Yes” List:

Dates of service:

Branch or component:

Date & type of discharge:

Concerning your current employer and for all of your employment during the last ten years, list your

employer’s name, business address, type of business, occupation or job title, and period(s) of

employment.

Employer’s Name & Location Type of Business Occupation Title Period

______________________________________________________________________________

Have you ever been employed by any state, district, or local governmental agency in Florida?

Yes ___ No ___

If “Yes”, identify the position(s), the name(s) of the employing agency, and the period(s) of employment:

Position Employing Agency Period of Employment

______________________________________________________________________________

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Have you previously been appointed to any office that required confirmation by the Florida Senate?

Yes ____ No ____

If “Yes”, list:

(1) Title of Office: _______________________________________

(2) Term of Appointment: _________________________________

(3) Confirmation Result: __________________________________

Have you ever been refused a fidelity, surety, performance, or other bond? Yes ___ No ___

If “Yes”, explain:

License/Certificate Title/Number Date Issued Issuing Authority Disciplinary Action/Date

______________________________________________________________________________

Section 3- Possible Conflicts of Interest

Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or

other direct dealings during the last four (4) years with any state or local governmental agency in Florida,

including the office or agency to which you have been appointed or are seeking appointment?

Yes ____ No ____

If “Yes”, explain:

Name of Business Your Relationship to Business Business Relationship to Agency

______________________________________________________________________________

Have members of your immediate family (spouse, child, parents(s), siblings(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 (4) years with any state or local governmental agency in Florida,

including the office or agency to which you have been appointed or are seeking appointment?

Yes ___ No ___

If “Yes”, explain:

Name of Business Relationship to You Relationship to Business Business Relationship to Agency

______________________________________________________________________________

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Have you ever been a registered lobbyist or have you lobbied at any level of government at any time

during the past five (5) years? Yes____ No____

(1) Did you receive any compensation other than reimbursement for expenses? Yes__ No__

(2) Name of agency or entity you lobbied and the principal(s) you represented:

Agency Lobbied Principal Represented

______________________________________________________________________________

Are there any possible conflicts of interest that could affect your ability to serve as a gubernatorial

appointee?

______________________________________________________________________________

If you agree, please type or write your initials for each of the following statements:

(1) If appointed, I agree to follow, as applicable to the position, Florida’s public records and open

meeting laws. _______

(2) If appointed, I agree to follow, as applicable to the position, the Code of Ethics for Public

Officers and Employees, Part III, Chapter 112, F.S. ______

Section 4- References and Experience

State your experiences and interests or elements of your personal history that qualify you for this

appointment:

______________________________________________________________________________

Please list specifically any degree(s), professional certification(s), or designations(s) related to the subject

matter of this appointment:

______________________________________________________________________________

Please list any awards or recognitions you have received relating to the subject matter of this

appointment:

______________________________________________________________________________

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Please identify all association memberships and offices (including any business, professional,

occupational, civic, or fraternal organizations) you have held or hold relating in the last 10 years:

Name of the Association Role Dates of Membership

______________________________________________________________________________

Do you know of any reason why you will not be able to attend fully to the duties of the office or position

to which you have been or will be appointed? Yes ____ No ____

If “Yes”, explain:

______________________________________________________________________________

List three persons who have known you well within the past five (5) years. Include a current telephone

number. Exclude your relatives and members of the Florida Senate.

Name Organization Phone Number

______________________________________________________________________________

In the following space, please explain why you want to serve as a gubernatorial appointee and share

anything else that you think may be helpful:

______________________________________________________________________________

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Section 5- Certification and Signature

_____I understand that any appointment tendered to me will be contingent upon the results of a

background investigation, and I am aware that withholding information or making false statements on this

application may be the basis for non-appointment by the Executive Office of the Governor and criminal

penalties. I agree to these conditions, and I declare that I have read the foregoing application and any

attachments and the facts stated within them are true, correct, and complete to the best of my knowledge

and belief

.

____ By checking this box and typing my name below I am electronically signing my application and

understand that an electronic signature has the same force and effect as a written signature.

/s/ _________________________ ______ ____________________________ _____

First Name Middle Initial Last Name Suffix

Please save this document to upload with your board

application.

If you have any questions, please call (850) 717-9243 or email

Appointments@eog.myflorida.com

Fill Online, Printable, Fillable, Blank Board Appointments Application V1 Form

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Fillable Board Appointments Application V1

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