Fillable - Updated Questionnaire( Typeable)51311 (Florida Division of Corporations)

Fill Online, Printable, Fillable, Blank - Updated Questionnaire( Typeable)51311 (Florida Division of Corporations) Form

Use Fill to complete blank online FLORIDA DIVISION OF CORPORATIONS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

- Updated Questionnaire( Typeable)51311 (Florida Division of Corporations)

On average this form takes 46 minutes to complete

The - Updated Questionnaire( Typeable)51311 (Florida Division of Corporations) form is 9 pages long and contains:

  • 0 signatures
  • 19 check-boxes
  • 177 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Florida Division of Corporations forms online.

BROWSE FLORIDA DIVISION OF CORPORATIONS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Questionnaire for Senate Confirmation
QUESTIONNAIRE FOR SENATE CONFIRMATION
The information from this questionnaire will be used by 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 blue or black ink.
Date Completed
1. Name:
Mr./Mrs./Ms. Last First Middle/Maiden
2. Business Address:
Street Office # City
Post Office Box State Zip Code Area Code/Phone Number
3. Residence Address:
Street City County
Post Office Box State Zip Code Area Code/Phone Number
Specify the preferred mailing address: Business
4. A. List all your places of residence for the last five (5) years.
Residence Fax #
(optional)
Address City & State From To
B. List all your former and current residences outside of Florida that you have maintained at any time during adulthood.
Address City & State From To
5. Date of Birth: Place of Birth:
6. Social Security Number:
7. Driver License Number: Issuing State:
8. Have you ever used or been known by any other legal name? Yes
No If “Yes” Explain
9. Are you a United States citizen? Yes
No If “No” explain:
If you are a naturalized citizen, date of naturalization:
10. Since what year have you been a continuous resident of Florida?
11. Are you a registered Florida voter? Yes No If “Yes” list:
A. County of Registration: B. Current Party Affiliation:
12. Education
A. High School: Year Graduated:
(Name and Location)
B. List all postsecondary educational institutions attended:
Name & Location Dates Attended Certificates/Degrees Received
13. Are you or have you ever been a member of the armed forces of the United States? Yes No If “Yes” list:
A. Dates of Service:
B. Branch or Component:
C. Date & type of discharge:
14. 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
15. Concerning your current employer and for all of your employment during the last five years, list your employer’s name, business
address, type of business, occupation or job title, and period(s) of employment.
Employer’s Name & Address Type of Business Occupation/Job Title Period of Employment
16. 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
17. A. State your experiences and interests or elements of your personal history that qualify you for this appointment.
B. Have you received any degree(s), professional certification(s), or designations(s) related to the subject matter of this
appointment? Yes
No If “Yes”, list:
C. Have you received any awards or recognitions relating to the subject matter of this appointment? Yes
No
If “Yes”, list:
D. Identify all association memberships and association offices held by you that relate to this appointment:
18. Do you currently hold an office or position (appointive, civil service, or other) with the federal or any foreign government?
Yes
No If “Yes”, list:
19. A. Have you ever been elected or appointed to any public office in this state? Yes
No If “Yes”, state the office title,
date of election or appointment, term of office, and level of government (city, county, district, state, federal):
Office Title Date of Election or Appointment Term of Office Level of Government
B. If your service was on an appointed board(s), committee(s), or council(s):
(1) How frequently were meetings scheduled:
(2) If you missed any of the regularly scheduled meetings, state the number of meetings you attended, the number you missed,
and the reasons(s) for your absence(s).
Meetings Attended Meetings Missed Reason for Absence
20. Has probable cause ever been found that you were in violation of Part III, Chapter 112, F.S., the Code of Ethics for Public Officers
and Employees? Yes
No If “Yes”, give details:
Date Nature of Violation Disposition
No If “Yes”, list:21. Have you ever been suspended from any office by the Governor of the State of Florida? Yes
A. Title of office: C. Reason for suspension:
B. Date of suspension: D. Result: Reinstated
Removed Resigned
22. Have you previously been appointed to any office that required confirmation by the Florida Senate? Yes No
If “Yes”, list:
A. Title of Office:
B. Term of Appointment:
C. Confirmation results:
23. Have you ever been refused a fidelity, surety, performance, or other bond? Yes
No If “Yes”, explain:
24. Have you held or do you hold an occupational or professional license or certificate in the State of Florida? Yes No
If “Yes”, provide the title and number, original issue date, and issuing authority. If any disciplinary action (fine, probation,
suspension, revocation, disbarment) has ever been taken against you by the issuing authority, state the type and date of the
action taken:
License/Certificate Original
Title & Number Issue Date Issuing Authority Disciplinary Action/Date
25. A. Have you, or businesses of which you have been and 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
B. 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:
Family Member’s Family Member’s Business’ Relationship
Name of Business Relationship to You Relationship to Business to Agency
26. 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
A. Did you receive any compensation other than reimbursement for expenses? Yes
No
B. Name of agency or entity you lobbied and the principal(s) you represented:
Agency Lobbied Principal Represented
27. List three persons who have known you well within the past five (5) years. Include a current, complete address and
telephone number. Exclude your relatives and members of the Florida Senate.
Name Mailing Address Zip Code Area Code/Phone Number
28. Name any business, professional, occupational, civic, or fraternal organizations(s) of which you are now a member, or of
which you have been a member during the past five (5) years, the organization address(es), and date(s) of your membership(s).
Name Mailing Address Office(s) Held & Term Date(s) of Membership
29. 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:
30. If required by law or administrative rule, will you file financial disclosure statements? Yes No
CERTIFICATION
STATE OF FLORIDA
COUNTY OF ____________________________________
Before me, the undersigned Notary Public of Florida, personally appeared
,
who, after being duty sworn, say: (1) that he/she has carefully and personally prepared or read
the answers to the foregoing questions; (2) that the information contained in said answers is
complete and true; and (3) that he/she will, as an appointee, fully support the Constitutions of the
United States and of the State of Florida.
Signature of Applicant-Affiant
Sworn to and subscribed before me this day of , 20 .
Signature of Notary Public-State of Florida
(Print, Type, or Stamp Commissioned Name of Notary Public)
My commission expires:
Personally Known
OR Produced Identification
Type of Identification Produced
(seal)
MEMORANDUM
AS A GENERAL MATTER, APPLICATIONS FOR ALL POSITIONS
WITHIN STATE GOVERNMENT ARE PUBLIC RECORDS WHICH
MAY BE VIEWED BY ANYONE UPON REQUEST. HOWEVER,
THERE ARE SOME EXEMPTIONS FROM THE PUBLIC RECORDS
LAW FOR IDENTIFYING INFORMATION RELATING TO PAST
AND PRESENT LAW ENFORCEMENT OFFICERS AND THEIR
FAMILIES, VICTIMS OF CERTAIN CRIMES, ETC. IF YOU
BELIEVE AN EXEMPTION FROM THE PUBLIC RECORDS LAW
APPLIES TO YOUR SUBMISSION, PLEASE CHECK THIS BOX.
Yes, I assert that identifying information provided in this application
should be excluded from inspection under the Public Records Law.
Because: (please provide cite.)________________________
IF YOU NEED ADDITIONAL GUIDANCE AS TO THE
APPLICABILITY OFANY PUBLIC RECORDS LAW EXEMPTION
TO YOUR SITUATION, PLEASE CONTACT THE OFFICE OF THE
ATTORNEY GENERAL.
The Office of the Attorney General
PL-01, The Capitol
Tallahassee, Florida 32399
(850) 245-0150
Senate Confirmation Questionnaire
Please mail to: Room316, R.A. Gray Building, 500 South Bronough Street, Tallahassee, Florida 32399-0250
The information from this page has been requested and will be used exclusively for Minority Statistics.
Please type or use blue ink.
1. Board of Interest:
2. Current Employer and Occupation:
3. Are you applying for reappointment: Yes No
4.
*Do you have a disability? Yes
this appointment, if applicable.
No If “Yes”, please describe your disability that would qualify you for
5.
*Sex: Male Female
6. *Race: White African-American
Hispanic-American
Asian/Pacific Islander
Native-American/Alaskan Native
7. Do you now, or have you, within the last three years, been a member of any club or organization that, to your
knowledge, in practice or policy, restricts membership or restricted membership during the time that you
belonged on the basis of race, religion, national origin, or gender? If so, detail the name and nature of the club(s)
or organization(s), relevant policies and practices, and state whether you intend to continue as a member if you
appointed by the Governor.
8. One of the Governor’s top priorities is to improve the conditions of the children living in our state. Would you
be willing to spend an hour a week with a child in need in your community? If so, please identify the type of
program and/or activity you would be willing to participate in as a mentor.
Applicant’s Name, including name commonly used
(Please print)
* This information will be used to provide demographic statistics and is not requested for the purpose of
discriminating on any basis
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

- Updated Questionnaire( Typeable)51311 (Florida Division of Corporations)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document