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004405 CITY OF BOYNTON BEACH
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-7-ON 0 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.
r 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 )
L entirety, t rm will be returned for clarification.
Name `(C't e 'M - DYlgz y Telephone # 1c6i— G Vi-Zj(l
Address 7.6 j1/4�ri.,00C 104,4)6 Zip Code 33t/24
E-mail Address: A 12.ye/ZZ V 4Di, GPM
Current occupation or, if retired, P6r-r-ieeD Cooti- geoie4e r-Lci
prior occupation
Education *//ft /PtX ,Q✓op 7 W t9 #z. . eH D L
Areou a registered voter? Yes No
y
Do you reside within the Boynton Beach City limits? ✓Yes No�No
Do you own/manage a business within the City limits: Yes
If"yes", name of business No
Are you currently serving on a City board? Yes!/ Yes No
Have you served on a City board in the past?
If so, which b ard(s) and when? 84
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Have you ever been convicted of a crime?
� where
If so, when 4/
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 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 ' •`' ' I `
**List Branch of Military Service or Organization on Reverse Side.
S:\CC\WP\BOARDS\APPMENTS\Master Form-Talent Bank Form.doc Revised 1/11/2007 11:16 AK--
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.
I have previously served on the City's Nuisance Abatement Board. After that was
abolished, I served on the Code Compliance Board, as an Alternate Member, from April
2005 to October 2005, and in October I was appointed as a Permanent Member. In
addition, I was elected by the Board as First Vice Chair in June of 2006 and have held
that position since that time. I am well qualified to continue as a Permanent Member of
this Board, and have no desire to serve on any other boards at the present time. I would
greatly appreciate your consideration in re-appointing me to this Board as a Permanent
Member.
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 t • the statements a answers provided herein are true and accurate. I understand that,
if appointed, a fal e statements y cause for removal from a board.
Signature: Date: �tZZ/o?
Revised 1/18/07 4:20 PM
S:\CC\WP\BOARDS\APPMENTS\Master Form-Talent Bank Form.doc