2007 Agee 03/20/2007 14:40 6090 CITY CLERK PAGE 01/04
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I CITY OF BOYNTON BEACH
"rO N e,c ADVISORY BOARD APPOINTMENT APPLICATION
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 dearly. 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 n
for clarification. 73-7— o 6 tt liv th
Name f)'? V-C r I 6-. 1 le( Telephone # -i 0 /` / 5-1-61 o( 1c
Address 532- 3 33"191( B R.-"CA(' zip code 334.135
E-mail Address: 9( 1 Ca 1�"d�`
Current occupation or, ' 41 .1-144it__
C Y1/b�C� p�/Vle ,'prior occupation /
Education 6 I L J 1 1 alA
Are you a registered voter? %/ Yes No
Do you reside within the Boy on Beach City limits? ,/ Yes No
Do you own/manage a business within, be C'ityel its: i/ Yes No
If"yes", name of business i � ( . Cc Q 'Yk-D
Are you currently serving on a City board? ° 4 L' Yes No
Have you served on a City board in the past? ,/Yes No
If so, which board(s) and when? fl
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ea A. & Bo d
Have you ever been conviSerli of crime?
If so, when AV / A where
Please indicate (by number) to which advisory board(s) you are seeking appointment. You may serve on
only one board. Please do not check more than three boards. Prioritize your choices by number, 1 being
the most desired and 3 being the least preferable. For board requirements, responsibilities and meeting
times and dates, see the attached listing.
Arts Commission Firefighters'Pension Trust Fund
/ Building Board of Adjustment &Appeals Golf Course Advisory Committee
Cemetery Board Library Board
Code Compliance Board 4 Planning & Development Board
Community Redevelopment Agency* Police Officers'Retirement Trust Fund
Community Relations Board Recreation & Parks Board
Education and Youth Advisory Board Senior Advisory Board
Employees'Pension Board Veterans Advisory Commission**
*Resume required
**Ust Branch of Military Service or Organization on Reverse Side.
S:\CC\WP\BOARDSWPPMENTS\Master Form-Talent Bank Form.doc Revised 1/11/2007 11:16 AM
03/20/2007 14:40 6090 CITY CLERK PAGE 02/04
voiti)
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.
Choice: j k-(%k-0/1-( A-Q/ r-'d )9o- a cks
Choi
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Second �aV
Choice:I j �—
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. O. 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.
Si I 0 '
Signature: °� (�
g '=� � /� Date: 0 3
Revised 1/18/07 4:20 PM
S:\CC\WP\BOARDS\APPMENTS\Master form-Talent Bank Form.doc