HomeMy WebLinkAboutHale, TiAnna Veteran and Veteran Family Application 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.
First Name Middle Initial Last Name
S-�8 'C
V&O Oat k�' U/J—
Home Address Suite or Apt
City r Sean s �'L 3a769
Y State Postal Code
What district do you live in?
None Selected
+i CA P1 1411 kA le, M 0,'m
Email Address (�
�16 d337.39"
Primary Phone Alternate Phone
✓e,
Occupation
Which Boards would you like to apply for?
None Selected
u P"'V, e-
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?
0 Yes r No
Do you live within the city limits of Winter Springs
qq Yes r No
How long have you been a resident of Winter Springs?
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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 a No
Do you currently serve on any other City of Winter Springs board or committee?
r Yes O 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?
r Yes 0 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?
M Yes r No
Are you related to a City of Winter Springs Commission member by blood, adoption, or
marriage?
r YesO No
If yes to the above, please provide relation
Interest & Experiences
Why are you interested in serving on a board or committee?
Cc,o0vo
Briefly state any specialized knowledge or prior experience you have that would be useful in
assisting the board or committee in accomplishing its purpose.
FO(gCV C'It CD(Y� UiAe r
Briefly state any experience you have in serving on any governmental board or committee.
\Q t 1
Financial Disclosure Requirement
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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*
None Selected
Gender*
None Selected
(V1301 �gN
Date of Birth
Do you have a physical disability?
6 Yes r 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'✓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.
Ik I Agree
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