HomeMy WebLinkAboutApplication for Appointment to Seat Three - 2018 02 27 - Final
CITY OF WINTER SPRINGS, FLORIDA
1126 EAST STATE ROAD 434
WINTER SPRINGS, FLORIDA 32708-2799
TELEPHONE: (407) 327-1800
FACSIMILE: (407) 324-4753
WEBSITE: www.winterspringsfl.org
APPLICATION FOR APPOINTMENT TO CITY COMMISSION SEAT THREE
ORIGINAL APPLICATION AND ALL OTHER DOCUMENTS WITH ORIGINAL SIGNATURES MUST
BE RECEIVED IN THE OFFICE OF THE CITY CLERK BY NOON ON MARCH 9, 2018:
Please be aware that documents submitted to the City are public records available for inspection to the extent allowed by Chapter 119, Florida Statutes.
Please complete the following in the space provided (either print or type):
A. GENERAL
Name:
Date of birth:
Phone (Cell):
Phone (Other):
Email:
Address:
City:
State:
ZIP Code:
Occupation (if retired, indicate last held position):
Education (if applicable):
B. ELIGIBILITY
The information provided in this section is for purposes of determining whether you are eligible to serve on the City Commission:
1a. Are you duly registered to vote in Seminole County? YES NO
1b. Are you duly registered to vote in the City of Winter Springs? YES NO
2a. Do you live within the City limits of Winter Springs? YES NO
2b. What district do you reside in? District 1 District 2 District 3 District 4 District 5
2c. How long have you been a resident of the City?
2d. How long have you resided in the District selected in 2b?:
3. 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 purposes of this question.
YES NO
4a. Do you presently serve on any other City of Winter Springs board or committee?
4b. If you answered “yes” to question 4a, please list each:
5. 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 the City Commission? YES NO
6a. 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
6b. Are you related to a City of Winter Springs Commission member by blood, adoption or marriage?
YES NO
6c. If you answered “yes” to question 6b, please indicate relationship:
NOTE: We would encourage you to submit with this completed Application:
A brief Bio (to include background information, information related to any applicable qualifications and
current/previous community service)
Letter of Intent (to include any information related to why you would be a good candidate to fill this open
Commission Seat
Please be advised that Members of the City Commission must submit a Form 1 (Statement of Financial Interests)
by July 1st of each year; and may be required to take up to 4 hours of mandatory Ethics related training
E. SIGNATURE
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.
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 THE CITY COMMISSION. IF
APPOINTED IT IS YOUR SOLE OBLIGATION AND DUTY TO COMPLY WITH SUCH LAWS.
Signature:
Date:
ORIGINAL APPLICATION AND ALL OTHER DOCUMENTS WITH ORIGINAL SIGNATURES MUST
BE RECEIVED IN THE OFFICE OF THE CITY CLERK BY NOON ON MARCH 9, 2018.
FAILURE TO TIMELY FILE AN APPLICATION MAY RESULT IN YOUR APPLICATION NOT BEING CONSIDERED BY THE CITY COMMISSION.
F. IN-OFFICE USE ONLY
RECEIVED BY:
____________________________________________
DATE STAMP:
Revised 02 27 2018