Revised June 2020
Boards and Committees
Application for Initial Appointment
(Voluntary Position)
Please read before completing application:
If you are seeking reappointment to a board or committee on which
you are presently serving, please complete the Application for
Reappointment instead of this application.
Pursuant to Chapter 119, Florida Statutes, this application and other
related written or electronic communication shall become a public
record and is subject to public disclosure.
Completed applications will be kept on file for two (2) years from the
date received in the Office of the City Clerk.
You may be required under Florida law to submit a Financial Disclosure
Form 1 (see wwww.ethics.state.fl.us).
Appointment to a City of Tampa Board and/or Committee requires
compliance with the City of Tampa Ethics Code and Florida law
concerning appointed officials.
All candidates selected for appointment may be subject to a criminal
background check.
Many volunteer committees, boards, and commissions (whether at the
city, county, or state level) are classified as an ‘office’ under Florida
Statutes. The Florida Constitution prohibits anyone from holding more
than one such ‘office’ at the same time. Please verify with the City
Clerk if you are unsure as to whether the position to which you are
applying qualifies as an ‘office’ under Florida law.
1. Board/Committee of Interest: ___________________________
2. Name ______________________________________________
Last First Middle
3. Date of Birth ___________ Place of Birth __________________
4. Home Address ____________________________________________
Length of time at current address ___________________
Phone ____________ Email ____________________
Revised June 2020
5. Please state how long you have been a resident of the City of Tampa
and/or Hillsborough County
______________________________________________________
Are you a registered voter in the City of Tampa? Yes ___ No ___
If
a resident of the City of Tampa, please state your voting district ___
(if unsure, use ‘My Precinct Finder’ at votehillsborough.org)
6. C
urrent Employer _____________________________________
Address_____________________________________________
Jo
b Title ______________________ Years at job ___________
Wo
rk Phone ___________ Work email ___________________
7. N
ote: The following information will be used to satisfy Equal
Opportunity reporting requirements.
Sex: M ___ F ____
Race: _______________
8. A
re you a United States citizen? Yes ____ No _____
9. P
lease state why you want to serve on the board/committee for which
you are applying, and why you believe you are qualified to serve.
Please include any relevant education, training, work history, volunteer
experience, and/or any other information that you wish to have
considered.
Select One
Revised June 2020
If you answer ‘yes’ to any of the following questions, please provide details
in the box below.
10. Are you currently serving in any position appointed by City
Council, the Mayor, Hillsborough County, or any other governmental
agency? Yes ___ No ___
11
. Have you ever held a professional or business license/certificate?
Yes ___ No ___
12
. Do you have any relatives employed by the City of Tampa?
Yes __ No __
13
. Have you or any members of your immediate family (or any
business for which you or your immediate family have been an owner,
officer, or employee) held any contractual or other dealings during the
past three (3) years with any City of Tampa agency? Yes ___ No ___
14
. Do you have a physical disability? Yes ___ No ___
Exp
lanation for any ‘yes’ answer to questions 10-14:
Revised June 2020
By my signature below, I affirm that all of the information provided in this
application is true and complete to the best of my knowledge, and authorize
the City of Tampa to conduct a criminal background investigation as part of
its selection process:
________________________ (
e-signature?
)
Date Completed: ___________________
Please send your completed application via U.S. Mail, fax, or email to:
Office of the City Clerk
Old City Hall
315 E. Kennedy Blvd., Third Floor
Tampa, FL 33602
Fax: (813) 274-8306
Email: Sandy.Marshall@tampagov.net
OFFICE USE ONLY:
Date Received: _____________ Received by: _____________________
Transmitted to ______________________ on ________________
Submit the Application via Email
click to sign
signature
click to edit
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