DS-DE #69 (eff. 1-29-06)/(R1S-2.0115) Page 2 of 2
Certification Application for Supervisor of Elections for Special Qualification Salary
10. Credit in Area V: Continuing Education Activities
a. I attended the following conference(s), program(s), seminar(s) or workshop(s) conducted or
sponsored by the Division of Elections, the Florida State Association of Supervisors of
Elections, the Elections Assistance Commission (EAC), the Federal Election Commission
(FEC), by the International Association of Clerks, Recorders, Elections Officials and
Treasurers (IACREOT), by the Election Center, by the Florida Elections Commission, or by
the Florida Commission on Ethics and:
_____ I have previously submitted to the Division of Elections documentation in support of
my attendance.
_____ I have attached to this application documentation in support of my attendance.
Provide on a separate sheet as Attachment “A”, the following for each conference,
program, seminar or workshop: name or title, the name of who conducted or sponsored the
event, the subject matter(s), the date(s) and length of attendance (number of hours), or
number of pre-approved continuing education credits. If you were unable to attend in person,
please affirm for each applicable conference, program, seminar or workshop if you listened
to an audio or video recording and read accompanying materials
b. I attended the following conference(s), program(s), seminar(s) or workshop(s) conducted or
sponsored by an entity other than one listed under paragraph 10a. and
_____ I have previously submitted to the Division of Elections documentation in support
of my attendance.
_____ I have attached to this application documentation in support of my attendance.
Provide on a separate sheet as Attachment “B”, the following for each conference,
program, seminar or workshop: name or title, the name of who conducted or sponsored the
event, the subject matter(s), the date(s) and length of attendance (number of hours), or
number of pre-approved continuing education credits. If you were unable to attend in person,
please affirm for each applicable conference, program, seminar or workshop if you listened
to an audio or video recording and read accompanying materials
______________________________ _________________
(Signature) (Date)
______________________________
(County)
IT IS A FIRST DEGREE MISDEMEANOR OFFENSE FOR ANY PERSON TO MAKE A FALSE STATEMENT IN A PUBLIC RECORD UPON
WHICH A GOVERNMENTAL ENTITY OR PERSONNEL MAY RELY (Section 837.06, Florida Statutes)
