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HomeMy WebLinkAbout2023 02 03 Jacobson, Richard Application.pdfSubmit Date: Feb 03, 2023 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 2 Which Boards would you like to apply for? Parks and Recreation 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? 30 years Richard M Jacobson 1628 Eagle Nest Circle Winter Springs FL 32708 richj407@gmail.com Mobile: (407) 415-5154 Home: (407) 366-4299 Retired Richard M Jacobson 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 If yes to the above, please provide relation Interest & Experiences Why are you interested in serving on a board or committee? 1) My home of 30 years backs up to Sam Smith Park/Lake 2) I am an avid Pickleball competitor Briefly state any specialized knowledge or prior experience you have that would be useful in assisting the board or committee in accomplishing its purpose. I have served on multiple boards during my 42-year career in the fashion industry. In my capacity as Sales Manager, one of my most critical duties was to be able to receive input from my salesforce so that I could convey a singular strong message back to the design team. Briefly state any experience you have in serving on any governmental board or committee. N/A Richard M Jacobson Date of Birth Financial Disclosure Requirement 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 * Male 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 09/06/1953 Richard M Jacobson