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Home My WebLink About2014 02 24 Other, Documents handed out relating to Item "600" Date: February 24, 2014 These two (2) documents were passed out amongst the Mayor and City Commission during the February 24, 2014 City Commission Regular Meeting, and were related to Regular Agenda Item "600". REECEiAtED Y-" rt ' 201 CITY OF WINTER SPRINGS cm.'OF V.,f!),J1 4..pRINCiEz OrFl:vt OF THF_GOY r,Oliin APPLICATION FOR APPOINTMENT TO CITY BOARD/COMMITTEE Applications may be submitted in person at City Hall, facsimile (407-327-4753), or email, ( CitvClerDeoartment[c7winterspringsfl.org ). Applicants may attach a resume, references, recommendations, or other such documentation that the applicant desires to have the City Commission consider. 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: A. GENERAL � 6gteeiZeir.4`1. Name: ,r►h E C 2. Home Address: / 6 3..S )yo v Ti)t e 3. Occupation: Z. , G - ► u Ili 5M c c 7 t 4. Telephone(cell): --70' a " (v3 5I Telephone(other): 5. Email: Lam-. ee iJ t,c0 ) iipt,44-1 L , G 041 041 B. ELIGIBILITY The information provided in this section is for purposes of determining whether you are eligible to serve on a City board or committee: 1a. Are you duly registered to vote in Seminole County: (Y)_71/(N) . lb. Are you duly registered to vote in the City of Winter Springs? 2a. Do you live within the City limits of Winter Springs: (Y)j(N) 2b. What district do you reside in? (1) (2) (3)✓(4) (5) 2c. How long have you been a resident of the City? 3ty`/t--5 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 f purposes of this question. CO_(N) 4a. Do you presently serve on any other City of Winter Springs board or committee?/✓(N) 4b. Please list each: (C/A,4,.43 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 this board or committee? (Y)_(N) V 6. 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 oard or committee. Do you voluntarily consent to having a standard background ch being performed on you by the City of Winter Springs? (Y) (N)_ 6a. Are you related to a City of Winter Springs Commission member by blood, adoption or/ marriage? (Y)__(N) V 6b. If yes to 6a, please provide relation: C. INTEREST AND EXPERIENCE Please see attached descriptions for each of the following boards or committees and indicate below on which board or committee you wish to serve. Please indicate your preference with a one (1) indicating your first choice and rank any additional choices with successive numbering. 1. Please indicate to which board or committee you are applying: _ Bicycle and Pedestrian Advisory Committee Board of Trustees T Code Enforcement Board Districting Commission (every 3 years, 2013) _9ak Forest Wall and Beautification District Advisory Committee Parks and Recreation Advisory Committee _Planning and Zoning Board/Local Planning Agency Tuscawilla Lighting and Beautification District Advisory Committee Other/Ad Hoc Committee 2. Briefly state why you are interested in serving on this board or committee (attach additional sheets as needed if interested in more .. than one Board): bl' nG3 f ! wl )'t ✓ .•^5 &I'L� µ7 (6M 44 iPL i/,- 6r Ile A At i Ito fS/s nr C /7AZ ?�I�� Al+�l (rte /�J /A1-:Fc i1 `,n 5:7 V e t1h F) 3. Briefly state any specialized knowledge or prior experience you have that would be useful in assisting the board or committee in accomplishing its purpose (attach additional sheets as needed if interested in m.re than one board): [ STvI(+ _ G 5r a_.. e ' c 4. Briefly state any experience you have in serving on any governmental board or committee: et 7/v- LC- ft)14c. I elz e-n A? Vfce a411 - rts-i 6,, Xt. D. 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. Please check the appropriate boxes: RACE GENI E" African-American Asian-American Female Hispanic-American Not Known Native American (/'Caucasian DISABILITY Not Known —Physically disabled 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 ACKNOWLED 11"4. 4; EXISTENCE OF THE CODE OF ETHICS FOR PUBLIC OFFICERS, AND THE FLORI INSHINE LAW, WHICH MAY PERTAIN TO YOU IF YOU ARE APPOINTED TO A C B•A•D OR COMMITTEE. IF APPOINTED IT IS YOUR SOLE OBLIGATION AND DU? 0 C? LY ITH SUCH LAWS. Signature: Date: Please return to: City of Winter Springs The Office of the City Clerk 1126 East State Road 434 Winter Springs, Florida 32708 2799 Revised 2114/2013 CITY OF WINTER SPRINGS APPLICATION FOR APPOINTMENT TO CITY BOARD/COMMITTEE Applications may be submitted in person at City Hall, facsimile (407-327-4753), or email, ( CityClerDepartmentAwinterspringsfi orq ). Applicants may attach a resume, references, recommendations, or other such documentation that the applicant desires to have the City Commission consider. 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: A. GENERAL 1. Name: HeAe,i-a E Vy\l 1 ou.�P_,r-� 2. Home Address: :987': E\cst'r-‘ r 3. Occupation: --at(e.c .. 4. Telephone (cell):-_- Telephone(other):407 --3S ---T1 03 5. Email: krLV -; 3 3 ( yc&V'ar> . rr� B. ELIGIBILITY The information provided in this section is for purposes of determining whether you are eligible to serve on a City board or committee: 1a. Are you duly registered to vote in Seminole County: (Y) J (N)___ lb. Are you duly registered to vote in the City of Winter Springs? 2a. Do you live within the City limits of Winter Springs: (Y).L (N) 2b. What district do you reside in? (1) (2) (3) (4) (5) 2c. How long have you been a resident of the City? y t 5 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. (Y)_(N) 4a. Do you presently serve on any other City of Winter Springs board or committee? 4b. 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 this board or committee? CO_(N)L City of Winter Springs 6. 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? (Y) / (N) 6a. Are you related to a City of Winter Springs Commission member by blood, adoption or marriage? (Y) (N) 6b. If yes to 6a, please provide relation: C. INTEREST AND EXPERIENCE Please see attached descriptions for each of the following boards or committees and indicate below on which board or committee you wish to serve. Please indicate your preference with a one (1) indicating your first choice and rank any additional choices with successive numbering. 1. Please indicate to which board or committee you are applying: —Bicycle and Pedestrian Advisory Committee _ Board of Trustees _Code Enforcement Board Districting Commission (every 3 years, 2013) _Oak Forest Wall and Beautification District Advisory Committee ./ Parks and Recreation Advisory Committee Planning and Zoning Board/Local Planning Agency Tuscawilla Lighting and Beautification District Advisory Committee Other/Ad Hoc Committee 2. Briefly state why you are interested in serving on this board or committee (attach additional sheets as needed if interested in more, than one Board): or) \tfLYN c- .yr ') 4)r CerNtet- ac( taeb C c B O.rvV a a 4.rr\ 1 IC °.rc-?°t Q k OE;s c rrt a � and hn v\c3kc•a A cy3 u p s insi_wtc \s. 3. Briefly state any specialized knowledge or prior experience you have that would be useful in assisting the board or committee in accomplishing its purpose (attach additional sheets as needed if interested in more than one, board): kr c.l3c-', Ck canes stir,tic- asr 1 o-Av Eta k.331 Q9rds r‘r\ nT3 Y10 ArN6A 0`Q ' 4 ,G rid 1. o x',r,-E r \ 1 c -c� Uui Q 00e7;50-1::1-1*. y 4`-o€ . 1 City of\'y Liter Springs 4. Briefly state any experience you have in serving on any governmental board or committee: rem rc i-N S 'v'J.S_ 5er,10 akt/iSnrzt3 encefd J n n e,,r,n ?r �tbrnrk.cLin s t Qom rr ee Sir-tie cm ,r4 OSIr-ntrA S 'Oc-� ec.Irr,,, D. 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. Please check the appropriate boxes: RACE GENDER African-American Male Asian-American 7 Female Hispanic-American ,Not Known --7 Native American a✓ Caucasian DISABILITY Not Known — Physically disabled 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 A CITY BOARD OR COMMITTEE. IF APPOINTED IT IS YOUR SOLE OBLIGATION AND DUTY TO COMPLY WITH SUCH LAWS. Signature: ' �_►. ..r �_.�!►,:. _ M 0 Date: z-/,_ r/4 Please return to: City of Winter Springs The Office of the City Clerk 1126 East State Road 434 Winter Springs, Florida 32708 2799 Revised 2/14/2013 City of Winter Springs