Appointment Information Form - Board of County Commissioners - Seminole County Government

To submit the form online, please complete the application below and click the submit button. You will be given the option to email a resume or additional information after submitting the form online. To print and mail the form, please download the printable form.
* = required field
NAME:
FIRST:	*
MIDDLE INITIAL:
LAST:	*
HOME ADDRESS:
ADDRESS 1:	*
ADDRESS 2:
CITY:	*
STATE:	*
ZIP CODE:	*
WORK/OFFICE ADDRESS:
ADDRESS 1:
ADDRESS 2:
CITY:
STATE:
ZIP CODE:
CONTACT INFORMATION:
HOME PHONE NUMBER:
OFFICE PHONE NUMBER:
CELL PHONE NUMBER:
EMAIL ADDRESS:	*
EMPLOYMENT INFORMATION:
EMPLOYER:
POSITION:
HOW LONG:
EDUCATION:
HIGH SCHOOL:
COLLEGE:
DEGREE RECEIVED:
If you currently or have ever held a professional or business license or certificate, please provide the title, issue date and issuing authority. If any disciplinary action has been taken, please state the type and date of the action taken:

BOARD INTEREST:
Please list the Boards or Committees on which you would prefer to be considered for appointment:

Do you wish to be considered for other Boards?
Yes No
Please state your experience and interests that you feel would qualify you as a candidate for appointment to the Board/Committee(s):

Florida law requires that members of certain boards file a detailed financial disclosure form. Would you be willing to serve on such a board?*
Yes No

TELL US ABOUT YOURSELF:
Are you a resident of Seminole County? *	Yes No
Are you a registered voter? *	Yes No
Do you own property in Seminole County? *	Yes No
Have you attended Seminole County's Citizens' Academy?	Yes No
Have you ever served on a County Board? *	Yes No
If yes, when and which boards(s)?

Seminole County strives to ensure that all County Boards are representative of the community. To assist in this endeavor, please check the applicable boxes:
ETHNICITY: *	African-American Caucasian (non-Hispanic) Hispanic Other
GENDER: *	Female Male
DATE OF BIRTH:
REFERENCES:
NAME:
ADDRESS:
PHONE NUMBER:

NAME:
ADDRESS:
PHONE NUMBER:

NAME:
ADDRESS:
PHONE NUMBER:
CERTIFICATION:
The Appointment Information Form, when completed and filed with the County Commission Office, is a PUBLIC RECORD under Chapter 119, Florida Statutes, and therefore is open to public inspection by any person. * I understand the responsibilities associated with being a Board member, and I have adequate time to serve on the above Board(s).