2009 Agee l'o �} CITY OF BOYNTON BEAC
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ADVISORY BOARD APPOINTMENT APPLICATION
/Vt0N 13
Thank you for your interest in serving on a City advisory board and for taking the time to fill out this form.
Please print or type all answers clearly. If interest is expressed in appointment to more than one
board, selections must be prioritized. If instructions are not followed or the application is not filled out in its
entirety, the form will be returned for clarification. t�
Name 13e l A7 c( Telephone # SCI -70/-or- /5 . .,c
Address g 3 1 -C 3 J i L - Zip Code 3.3 J35
E-mail Address: $ er f I ( t C1-/5 L' COY 1
Current occupation or, if retired,
prior occupation
,
Education 7' D of 1 �et ' fl 4 141( ,
)
Are you a registered voter. Yes No
Do you reside within the Boy ton Beach City limits? ✓ Yes No
Do you own/manage a business within e City limits: ✓ Yes No
If"yes", name of business S tt4& k ai►
Are you currentlyservingon a Cityboard? — .Yes No
Have you served on a City board in the past? V Yes No
If so, which board(s) an/ `l whe ? 0 el� d o 2 - 0-0 0 5 ( )
0 0 6 a J• . . ' Q dirt.dyytpvyti a-OW d _m Ac
Have you ever been convicted of a crime? I` °
If so, when where '
You may serve on only one board. Please indicate which advisory board(s) you are seeking appointment
AND whether as a regular member, alternate, or no preference. Prioritize up to three choices with number
1 being the most desired and 3 being the least preferable. For board listing, requirements, responsibilities
and meeting times and dates see pages 3 and 4 attached.
yts Commission Firefighters' Pension Trust Fund
ilding Board o ustment &Appeals Golf Course Advisory Committee
Cemetery Board Library Board
Code Compliance Board Planning & Development Board
Community Relations Board Police Officers' Retirement Trust Fund
Education and Youth Advisory Board Recreation & Parks Board
Employees' Pension Board Senior Advisory Board
Veterans Advisory Commission
Board Preferences:
Choice: d''^"J` 064 ' I member e: f
1 L(1diI tYP
2nd Choice (optional) member type:
3rd choice (optional) member type:
What personal qualifications do you possess (i.e., profession, previous experience, branch of military service
or organization) which you feel would make you a good candidate for this board? Please be specific.
First d 2 kayyti t( cvri
Choice:
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Choice:
Third
Choice:
Feel free to attach an extra sheet or resume. Return the completed form to the City Clerk's Office, 100 East
Boynton Beach Boulevard, City Hall. Mailing address: P. 0. Box 310, Boynton Beach, FL 33425-0310. It
will be placed in the City's Talent Bank, a file to which Commissioners may turn for candidates when board
openings occur.
I hereby certify that the statements and answers provided herein are true and accurate. I understand that,
if appointed, any false statements may be cause for removal from a board.
Signature: Date: if
Revised 10/30/08 1:29 PM
S:\CC\WP\BOARDS\APPMENTS\Master Form-Talent Bank Form.doc