Fillable Lee County Advisory Committee Application (Lee County Government)

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Lee County Advisory Committee Application (Lee County Government)

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The Lee County Advisory Committee Application (Lee County Government) form is 4 pages long and contains:

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  • 39 check-boxes
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Lee County Advisory Committee Application
Name of Advisory Committee You are Applying for:
Commission District:
[ ] 1 - Manning [ ] 2 - Pendergrass [ ] 3 - Sandelli [ ] 4 - Hamman [ ] 5 - Mann
Personal Information
Title: [ ] Mr. [ ] Mrs. [ ] Ms. [ ] Other:
Name:
Last First Middle Initial
Residence Address:
Street City Zip Code
Business Address:
Street City Zip Code
Mailing Address:
Street City Zip Code
Phone:
Home Cell Business
E-mail Address:
Employer Address:
Street City Zip Code
Employer Phone:
[ ] Go Paperless: I agree to receive communications concerning my membership via e-mail.
For Domestic Animal Services Advisory Committee Only
Select the category you are interested in representing:
[ ] Animal Breeder [ ] Animal Advocate / Rescue [ ] Cattlemen’s Association
[ ] Licensed / Practicing Veterinarian [ ] Service Animal Industry
Lee County Administration | 2115 Second Street | Fort Myers, FL 33901
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
Submit by E-mail
Lee County Advisory Committee Application
(Continued)
List your qualifications to be eligible (for all committees):
Do you have any family members currently serving on this Advisory Committee? If ‘Yes’, list below. [ ] Yes [ ] No
Do you, or anyone in your immediate family, have any business or contractual relationships with the
County? If ‘Yes’, explain the relationship and, if applicable, identify the family relationship (mother,
father, son, daughter, etc.)
[ ] Yes [ ] No
Have you ever been convicted of any felony or misdemeanor offense? If ‘Yes’, explain below (You
may omit minor traffic violations & any offence committed as a minor.)
[ ] Yes [ ] No
Have you ever worked for the Lee County Board of County Commissioners? If ‘Yes’, list position,
department, start & end date.
[ ] Yes [ ] No
Do you have any relatives currently working for the Lee County Board of County Commissioners?
If ‘Yes’, list name(s) & department(s).
[ ] Yes [ ] No
If applicable, attach a resume of additional personal and professional qualifications and experience.
Signature Date
•
Some Boards and Committees appointed by the Lee County Board of County Commissioners are required to comply with
Chapter 112, Florida Statutes, Financial Disclosure Law, and you may be required to file a Form 1 Statement of Financial
Interests.
•
Lee County, an Equal Opportunity Employer, considers the selection and appointment of persons to advisory committees
in a non-discriminatory manner consistent with the requirements of Federal, State and Local non-discrimination laws.
Returning completed form:
Regular Mail:
Lee County Administration
Fax:
(239) 485-2262
Advisory Committees
P.O. Box 398
E-mail:
advisorycommittees@leegov.com
Fort Myers, FL 33902-0398
Lee County Administration | 2115 Second Street | Fort Myers, FL 33901
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
click to sign
signature
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Lee County Advisory Committee Application
(Continued)
Committee ID# ________________________
(Office Use Only)
Lee County complies with Federal, State and Local laws, regulations and guidelines that prohibit
discrimination based on race, sex, color, national origin, handicap, age or marital status.
STATUTORILY CREATED REQUIRED COMMITTEE REPORTING DATA
Lee County is required by the State of Florida to collect and maintain the information requested below for
statistical reporting purposes only. This information will be maintained separately from your application and
will not be considered in the application evaluation process.
The information provided is required by State Statute, however, you have the right not to disclose any or all of
this information. This form must be returned to Lee County Administration.
Gender:
Male
Female
Choose Not to Disclose
Handicapped / Disabled:
Yes
No
Choose Note to Disclose
RACIAL / ETHNIC DATA (CHECK ONE)
WHITE (Not of Hispanic Origin): All persons having origins in any of the original people of Europe,
North Africa or the Middle East.
BLACK (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
ASIAN OR PACIFIC ISLANDER: All persons having origins in any of the original Peoples of the Far
East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example:
China, Japan, Korea, the Philippine Islands and Samoa
AMERICAN INDIAN OR ALASKAN NATIVE: All persons having origins in any of the original
Peoples of North America and who maintain cultural identification through tribal affiliation or
community recognition.
HISPANIC: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin regardless of race.
CHOOSE NOT TO DISCLOSE
Lee County Administration | 2115 Second Street | Fort Myers, FL 33901
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
Lee County Advisory Committee
Conflict of Interest
(Please Type or Print)
Advisory Committee:
Recommended or Appointed by:
Name: Phone:
Mailing Address:
Street City Zip Code
Email:
Employer/ Business:
Employer Address:
Street City Zip Code
POTENTIAL CONFLICTS OF INTEREST: Florida law prohibits certain business relationships on the part of public
officers and employees, including persons serving on advisory boards and committees. In general, advisory committee
members are prohibited from entering into transactions with the County. This includes contracts or transactions between
Lee County government and you, your outside employer/employment, or any business in which you have a material interest.
Please consult the excerpted guidelines on page 2 from the Guide to the Sunshine Amendment and Code of Ethics for Public
Officers and Employees for assistance in answering the questions below.
Are you aware of a potential conflict of interest that may result from your service as a member of a BoCC advisory
committee? [ ] Yes [ ] No
If yes, please explain the nature of the conflict of interest. For example, identify the contracts or business transactions you
have with the County, the position you hold with your employer if the employer has the contract or business relationship
with the County, identify the business entity you own or have a material interest, and any other information necessary to
explain the nature of the conflict of interest:
If you have a potential conflict but think that one of the statutory exemptions applies to your situation, please indicate the
specific exemption you claim (see Section 112.313(12), Florida Statutes):
If you have questions about a potential conflict, please contact the Lee County Attorney’s Office at (239) 533-2236.
WAIVER OF CONFLICTS OF INTEREST: A member of an advisory board may have a conflict of interest waived by the
BoCC after disclosure of the transaction or relationship using Florida Commission on Ethics Form 4A (Disclosure of
Business Transaction, Relationship or Interest). If you are seeking a waiver from the Board, you must return Form 4A in
addition to this Conflict of Interest form to County Administration as indicated on page 2. Waiver requests will be
forwarded to the County Attorney’s Office for review.
Advisory Committee members have a continuing duty to disclose potential conflicts of interest.
Lee County Administration | 2115 Second Street | Fort Myers, FL 33901
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
PROHIBITED EMPLOYMENT AND BUSINESS RELATIONSHIPS
1
1. Doing Business With One’s Agency
(a) You may not purchase, rent, or lease any realty, goods, or services for the County from a business entity in
which you, your spouse or child own more than a 5% interest. [Sec. 112.313(3), Fla. Stat.]
(b) You may not rent, lease or sell any realty, goods, or services to the County. [Sec. 112.313(3), Fla. Stat.]
2. Conflicting Employment or Contractual Relationship
(a) You may not be employed by or contract with businesses or agencies regulated by or doing business with the
County. [Sec. 112.313(7), Fla. Stat.]
(b) You may not hold any employment or have a contractual relationship that will pose a frequently recurring
conflict between your private interests and public duties, or which will impede the full and faithful discharge
of your public duties. [Sec. 112.313(7), Fla. Stat.]
(c) Limited exceptions to this prohibition have been created (see Sec. 112.313(7)(a) and (b), Fla. Stat.).
3. Exemptions—Pursuant to Sec. 112.313(12), Fla. Stat., the prohibitions against doing business with the County and having
conflicting employment may not apply:
(a) When the business is rotated among all qualified suppliers in the County.
(b) When the business is awarded by sealed, competitive bidding and neither you, your spouse, nor child have
attempted to persuade County personnel to enter the contract. NOTE: Ethics Commission FORM 3A must be
filed with the Supervisor of Elections prior to or at the time of bid submission
.
(c) When the purchase or sale is for legal advertising, utilities service, or for passage on a common carrier.
(d) When an emergency purchase must be made to protect the public health, safety, or welfare.
(e) When the business entity is the only source of supply within the County and there is full disclosure of your
interest to the governing body on Commission FORM 4A.
(f) When the aggregate of business transactions does not exceed $500 in a calendar year.
(g) When the business transacted is the deposit of County funds in a bank of which you are an officer, director, or
stockholder, so long as County records show that the BoCC has determined that you did not favor your bank
over other qualified banks.
1
Adapted from, Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees, State of Florida
Commission on Ethics (2012).
Lee County Administration | 2115 Second Street | Fort Myers, FL 33901
Phone: (239) 533-2221 | Email: advisorycommittees@leegov.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County
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Lee County Advisory Committee Application (Lee County Government)

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Completed 18 July 2020

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