Value Adjustment Board Application
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.
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
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
Phone: (239) 533-2221 | Email: email@example.com
Please be advised that all information contained in this application becomes Public Record once submitted to Lee County