HomeMy WebLinkAbout2021 02 22 Miller, Robert Application to Vet Board V E 1)11�
City of Winter Springs, FL Boards & Commissions E ii� 21
Application Form c, y v'
F
Profile
Please be aware that documents submitted to the City are public records available for
inspection to the extent all by Chapter 119, Florida Statutes.
Middle initial Last Name
First Name
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Suite or Apt
Horne Address
;,70le?
Slate Postal Cods,
City
What district do you live in?
None Selected
Email Address
Primary Phan Alternate Phone
)A� 1701 t
Occupation
is Boards of you like to apply for?
F-Bicycle and Pedestrian Advisory Committee
r-Board of Trustees
r--City Commission
r-Code Enforcement Board
r Oak Forest Wall and Beautification District Advisory Committee
r-Parks and Recreation Advisory Committee
r-Planning and Zoning Board/Local Planning Agency
r Tuscawilla Lighting&Beautification District Advisory Committee
"Veteran and Veteran Family Advisory Committee
Eligibility
Are you duly registered to vote in Seminole County?
Yes r No
Are you duly registered to vote in the City of Winter Springs?
'Pes r No
Page 1 of 3
Do you live within the city limits of Winter Springs
P<Yes r No
How long have you been a resident of Winter Springs?
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.
r Yes No
Do you currently serve on any other it of Winter Springs board or committee?
(- Yes F No
If yes to thea ove, please list each
Do you have any private or personal interests is might conflict with serving the City's
interests if you were to be appointed to serve on this board or committee?
(- Yes I(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 it of Winter Springs?
Yes r No
Are you related to a City of Winter Springs Commission member by blood, adoption, or
marriage?
r YesX No Veteran of the U.S. military discharged
Question applies to Veteran and Veteran Family Advisory Committee or released therefrom under
Select one of the following condiflons, other than dishonorable
None Selected 0 immediate farnk, ember of a veteran
or deceased veteran
If yes tothe above, please provide relation 0 Leader of a veteran organization
based in Winter Springs
Question applies to Veteran and veteran Family Advisory Committee
Please upload a copy of one of the following: Military/Veteran ID OR
proof of organization serving veterans & your role
Interest & Experiences
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Why are you interested in serving on a board or committee?
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Briefly state any specialized knowledge or prior experience you have that would be useful in
assisting the board or committee in accomplishing its purpose.
Di.
Briefly state any experience you have in serving on any governmental board or committee.
A9 Y4,401;
............ .....
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
Gender*
Date of Birth S'
Do you have a physical disability?
r Yes t No
Please Agree with the Following Statement
You hereby represent tote City of Winter Springs under penalties of perjury that the
information provided herein is true and accurate tote 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.
Agree
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