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2. This application is intended to provide information that will enable the City Commission to select the most qualified Board/Committee members. Please complete all applicable sections and return the form along with your current résumé to the City Clerk’s Office.
   
4. City of Fernandina Beach
   City Clerk’s Office
   204 Ash Street
   Fernandina Beach, FL 32034
   (904) 310-3115
   
6. Name*
8. Home Mailing Street Address*
10. City*
11. Zip Code*
13. Primary Phone*
14. Secondary Phone
16. 
    Please note that board materials are distributed electronically.
18. Email to receive board materials
20. Employer
21. Position Title
23. Business Address
25. City
26. Zip
28. 
    Select the advisory board/committee you are applying for:*
    -- Select One --Airport Advisory CommissionArts and Culture NassauAuditor Selection CommitteeBoard of AdjustmentBoard of Trustees of the Fire & Police Pension PlanBoard of Trustees of the General Employees Pension PlanCode Enforcement & Appeals BoardCommunity Development Block Grant Citizen Advisory TaskforceCRA Advisory BoardGolf Course Advisory BoardHistoric District CouncilHousing AuthorityMarina Advisory BoardPlanning Advisory BoardPEG Channel Committee Parks & Recreation Advisory CommitteeYouth Advisory Committee
30. 
    Additional board that you are applying for:*
    -- Select One --Airport Advisory CommissionArts and Culture NassauAuditor Selection CommitteeBoard of AdjustmentBoard of Trustees of the Fire & Police Pension PlanBoard of Trustees of the General Employees Pension PlanCode Enforcement & Appeals BoardCommunity Development Block Grant Citizen Advisory TaskforceCRA Advisory BoardGolf Course Advisory BoardHistoric District CouncilHousing AuthorityMarina Advisory BoardPlanning Advisory BoardParks & Recreation Advisory CommitteePEG Channel CommitteeYouth Advisory CommitteeNone
32. 
    
    Why are you interested in serving on this Board? Please explain.
34. 
    Eligibility
36. Are you a resident of the City?

    1. Yes

    1. No
37. Length of time:
39. Do you hold a public office?

    1. Yes

    1. No
40. Office name:
42. Are you employed by the City?

    1. Yes

    1. No
43. Position:
45. Are you currently serving on a Board?

    1. Yes

    1. No
46. Board Name:
48. Potential Conflict of Interest:

50. Have you ever been engaged in the management/ownership of any business enterprise that has a financial interest with the City of Fernandina Beach?

    1. Yes

    1. No
52. 
    If yes, please provide details:
54. Major Affiliations:
56. 
    List community, professional, or other applicable policy-making Boards on which you have served.
    Note the length of service and office held (if any):
58. Qualifications:
60. Please list any specific qualifications, education or experience that would directly relate to the Board for which you are being recommended:
62. Organization or Commissioner sponsoring nomination (if applicable):
64. Educational Background: (Check all that apply)

    1. High School
    2. AA

    1. BS/A
    2. MS/A

    1. J.D.

    1. Ph.D.
66. 
    Other:
68. 
    Major areas of study:
70. Florida’s Public Records Law, Chapter 119, Florida Statutes, states:
72. “It is the policy of this state that all state, county, and municipal records shall at all times be open for a personal inspection by any person.” Your application when filed will become a public record and subject to the above statute. In addition, any appointed member of a board of any political subdivision (except members of solely advisory bodies) and all members of bodies exercising planning or zoning, are required to file a financial disclosure form (Form1) within 30 days after appointment and annually thereafter, for the duration of the appointment as required by Chapter 112, Florida Statutes
74. I understand that if I am appointed to one of the City’s boards, I will be required to file a financial disclosure form - Form 1, as described above, and I am willing to comply with this requirement.
76. 
    I understand that any false, incomplete or misleading information given by me on the application is sufficient cause for rejection of this application. I understand and agree that any such false, incomplete or misleading information discovered on this application at any time after appointment to a Board may result in my removal.
78. 
    I also understand that all board appointments are for voluntary, uncompensated services. Additionally, if appointed, I am able to attend meetings and otherwise fulfill the duties of the office.
80. 
    Applications are submitted to the City Commission when vacancies occur and are effective for two years from date of completion.
82. Do you understand the duties and responsibilities of the Board/Committee that you are applying for?

    1. Yes

    1. No
84. 
    By submitting this form, I declare the foregoing facts to be true, correct, and complete.
86. Date*
88. Applicant’s Signature *
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit

* indicates a required field