Pertinent education or relevant technical skill:
Employment history (Please include last 3 employers, position and years served):
Present or prior service in governmental boards and committees:
Describe your professional and/or volunteer experience or background that would best qualify you for an
appointment to the Board/Committee/Commission you have selected:
If you are applying for a Board/Committee/Commission that has specific requirements, please detail how
your background and/or experience meets the required criteria:
If not selected for the Board/Committee/Commission indicated above, please list any additional
Boards/Committees/Commissions for which you would like your application submitted. (Please rank in
order of preference):
(1) (2)
(3) (4)
If appointed to serve, a Financial Disclosure Form is required, upon appointment, annually and upon
resignation/retirement.
If proof of residency is required by your Board/Committee/Commission, please provide a utility bill
and/or a lease.
If proof of ownership/interest in a business in North Miami is required, please provide a current certificate
of use and/or a business tax receipt.
Have you ever been convicted of a felony? Yes
No
Do you currently have a violation(s) of North Miami codes? Yes
No
If yes to either one of the questions above, please explain in detail:
I hereby attest to the accuracy and truthfulness of the application. I certify under oath, and penalty of
perjury, that all information shown above is true and correct. I do understand that any appointment to a
Board/Committee/Commission obtained on a misrepresentation of a material fact shall be null and void.
Signature: Date:
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