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HomeMy WebLinkAbout2020 11 19 Pehowic, Dorothy ApplicationSubmit Date: Nov 19, 2020 First Name Middle Initial Last Name Home Address Suite or Apt City State Postal Code Email Address Primary Phone Alternate Phone Occupation City of Winter Springs, FL Boards & Commissions Application Form Profile Please be aware that documents submitted to the City are public records available for inspection to the extent allowed by Chapter 119, Florida Statutes. What district do you live in? District 1 Which Boards would you like to apply for? City Commission: Submitted Veteran and Veteran Family Advisory Committee: Submitted Eligibility Are you duly registered to vote in Seminole County? Yes No Are you duly registered to vote in the City of Winter Springs? Yes No Do you live within the city limits of Winter Springs Yes No How long have you been a resident of Winter Springs? 1.5 years Dorothy M Pehowic 609 Anhinga Rd Winter Springs FL 32708 dorothypehowic@gmail.com Home: (520) 704-0398 Business: (407) 402-5088 Mental Health Therapist with aspecialty in trauma. Dorothy M Pehowic Please upload a copy of one of the following: Military/Veteran ID OR proof of organization serving veterans & your role Have you ever been convicted or found guilty, regardless of adjudication, of a felony in any jurisdiction? Any plea of nolo contendere (no contest) shall be considered a conviction for the purposes of this question. Yes No Do you currently serve on any other City of Winter Springs board or committee? Yes No If yes to the above, please list each Do you have any private or personal interests which might conflict with serving the City's interests if you were to be appointed to serve on this board or committee? Yes No City ordinance requires that all persons applying for a City board or committee must voluntarily consent to a standard criminal background check before being appointed to a board or committee. Do you voluntarily consent to having a standard background check being performed on you by the City of Winter Springs? Yes No Are you related to a City of Winter Springs Commission member by blood, adoption, or marriage? Yes No Question applies to Veteran and Veteran Family Advisory Committee Select one of the following * Veteran of the U.S. military discharged or released therefrom under conditions other than dishonorable Immediate family member of a veteran or deceased veteran If yes to the above, please provide relation I am an Army Veteran married to a retired Air Force Veteran Question applies to Veteran and Veteran Family Advisory Committee Interest & Experiences Why are you interested in serving on a board or committee? I would like to serve my community. Dorothy_Pehowic_DoD_Drivers_Lic_and_VA.pdf Dorothy M Pehowic Date of Birth Briefly state any specialized knowledge or prior experience you have that would be useful in assisting the board or committee in accomplishing its purpose. The specialized knowledge and exigencies that I have are in the following areas: Six years as an intel Army veteran, own and operate a private practice as a masters level psychodynamic mental health provider specializing in human behavior, trauma and domestic violence, former deputy sheriff with an A.S. in paralegal studies, active Judge Advocate for an American Legion Post 183 in Casselberry as well as a Lifetime Member out of the Winter Springs VFW. Briefly state any experience you have in serving on any governmental board or committee. None. State Reporting Requirements Florida law requires that the City annually submit a report to the Secretary of State disclosing race, gender, and physical disabilities of board and committee members. Ethnicity * Caucasian/Non-Hispanic Gender * Female Do you have a physical disability? Yes No Please Agree with the Following Statement You hereby represent to the City of Winter Springs under penalties of perjury that the information provided herein is true and accurate to the best of your knowledge and the City of Winter Springs has the right to rely on that information I Agree Please Agree with the Following Statement You hereby acknowledge the existence of the Code of Ethics for Public Officers and the Florida Sunshine Law which may pertain to you if you are appointed to a City Board or Committee. If appointed it is your sole obligation and duty to comply with such laws. I Agree 08/19/1967 Dorothy M Pehowic