City Clerk's Office
City of Orlando Citizen Board Application


Title:
Mr. Ms.
First Name:Last Name:MI:Suffix:
Residence Address
Street Address:


City:State:Zip Code:# Yrs at Current Address:


If you have lived at your current address for less than 5 years, complete your previous full residential address.
Previous Residence Address:City:State:Zip Code:



Work Address
Street Address:
City:State:Zip Code:Preferred Mailing Address:
Work Residence
Email Address:


Work Phone:


Extension:

Residence Phone:Cell Phone:Preferred Phone Contact:
Work Residence
Handicapped:
No Yes
Sex:
Male
Female
Birthday in MM/DD/YYYY:
Race:
AMERICAN INDIAN ARAB ASIAN OR PACIFIC ISLANDER BLACK (NOT OF HISPANIC ORIGIN) CAUCASIAN (NOT OF HISPANIC ORIGIN) HISPANIC OTHER
The Public Records Act makes Personnel records available for review by the public upon request. Section 119.071, Florida Statutes exempts photographs, home addresses and telephone numbers of specific categories of individuals from mandatory public access. If you meet this criteria please choose from the appropriate category:
N/A
Active or former law enforcement personnel, including correctional and probation officers, Department of Children and Family Services and Department of Health personnel whose duties include any type of child abuse or neglect investigation and personnel of the Department of Revenue or local governments whose duties include revenue collection or child support enforcement.
Firefighters certified in compliance with Section 633.35, Florida Statutes.
Current or former Supreme Court, District Court, Circuit Court and County Court Judges or Justices.
Current or former U.S. Attorneys, Assistant U.S. Attorneys, State Attorneys, Assistant State Attorneys, Statewide Prosecutors, Assistant Statewide Prosecutors.
Current or former human resources, labor relations, employee relations directors, assistant directors, managers, or assistant managers of any local government or water management district whose duties include hiring and firing employees, labor contract negotiation, administration, or other personnel related duties.
Current or former code enforcement officers.
Current or former guardians ad litem, as defined in Section 39.820, Florida Statutes see Section 119.071(d)(6).
Spouses and children of the above.



Interests and Activities:







Occupation:
Job Title:



Industry:
UNKNOWN CONTRACTOR HOMEMAKER OTHER SELF EMPLOYED
ADMINISTRATOR DESIGNER INSURANCE PLANNING / ARCHITECT STUDENT
ARCHITECT EDUCATION LANDSCAPE ARCHITECT PRESIDENT OF COMPANY TECHNOLOGY
ARTIST ENGINEER LEGAL PROFESSION REAL ESTATE UNEMPLOYED
COMMUNICATIONS FINANCIAL MANAGER / DIRECTOR / CEO RETIRED
BUILDING / CONSTRUCTION GOVERNMENT MEDICAL SALES
Employer:


Tenure in years:
Work Experience:












Community Involvement:









Education:
Institution:



Location:



Attended From (YYYY):



Degree:

Attended To (YYYY):
Institution:



Location:



Attended From (YYYY):



Degree:

Attended To (YYYY):



Institution:



Location:



Attended From (YYYY):



Degree:

Attended To (YYYY):
License Information:
Have you held a professional business license or certificates?   Yes No
If Yes, please provide the title, issue date and issuing authority.
License/Certificate Title:Issue Date:Issuing Authority:




License/Certificate Title:Issue Date:Issuing Authority:




License/Certificate Title:Issue Date:Issuing Authority:




References:
Name
Phone (xxxxxxxxxx)








Extension:









Extension:









Extension:


Board(s) Information:
Choice 1:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY
Choice 2:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY
Choice 3:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY

Applying for the Historic Preservation Board:
Yes No
If yes, which neighborhood do you reside in:
LAKE CHEROKEE LAKE COPELAND LAKE EOLA HEIGHTS LAKE LAWSONA COLONIALTOWN SOUTH DOWNTOWN OTHER

Miscellaneous Questions:
Are you a City of Orlando resident?? Yes No If yes, which District:
N/A 1 2 3 4 5 6
Are you a registered voter? Yes NoIf yes, which Precinct:

Do you own property in Orlando? Yes No N/A
Are you currently serving on a City Board? Yes No
If yes, which Board:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY
Have you ever served on a City Board? Yes No
If yes, which Board:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY

When YYYY:


Which Board:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY

When YYYY:


Which Board:
AFFORDABLE HOUSING ADVISORY COMMITTEE
APPEARANCE REVIEW BOARD
AUDIT BOARD
BOARD OF ZONING ADJUSTMENT
BUILDING & FIRE CODES BOARD OF APPEALS
CERTIFICATION BOARD
CHAPTER 57 REVIEW BOARD
CITIZENS POLICE REVIEW BOARD
CIVIL SERVICE BOARD
CODE ENFORCEMENT BOARD
CRIMINAL NUISANCE ABATEMENT BOARD
DOWNTOWN DEVELOPMENT BOARD
DOWNTOWN SOUTH NEIGHBORHOOD IMPROVEMENT DISTRICT
FAMILY, PARKS & RECREATION BOARD
HARRY P. LEU GARDENS BOARD OF TRUSTEES
HISTORIC PRESERVATION BOARD
HOUSING AUTHORITY
MENNELLO MUSEUM BOARD OF TRUSTEES
MUNICIPAL PLANNING BOARD
NOMINATING BOARD
N/A
ORANGE BLOSSOM TRAIL DEVELOPMENT BOARD
ORANGE COUNTY CIVIC FACILITIES AUTHORITY BOARD
ORANGE COUNTY LIBRARY BOARD OF TRUSTEES
ORLANDO UTILITIES COMMISSION
PUBLIC ART ADVISORY BOARD
VEHICLE FOR HIRE APPEAL BOARD
_ANY

When YYYY:


Are you currently serving on a Board, Authority or Commission for another governmental agency?

Yes No
If yes, which Board:When YYYY:


Which Board:When YYYY:


Which Board:When YYYY:


How long have you lived in Central Florida?

#Years
Why are you interested in serving on an Orlando Citizen Advisory Board:










Because of the number of persons expressing an interest in serving on the Orlando Boards and the important issues the Boards face, this Questionnaire was developed to assist the City's Nominating Board in its review process leading up to recommendation to the Mayor for appointments and ultimate confirmation by City Council. This Questionnaire, when completed and filed with the City Clerk, is a PUBLIC RECORD under Chapter 119, Florida Statutes, and is, therefore, open to public inspection by any person.

Thank you for your interest in serving on a City Board and for taking the time to complete this Questionnaire.


Disclosures:

Certain boards require members to file Limited Financial Disclosure, Gift Reporting and other State forms required by the Florida Commission on Ethics. If appointed to one of these Boards, would you be willing to comply with this requirement?   Yes No

Directions:

For purpose of the following questions, "relative" means father, mother, son, daughter, brother, sister, uncle, aunt, cousin, nephew, niece, wife, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepbrother, stepsisters, half brother, or half sister.

Question #1:
Are you or any of your relatives presently or formerly an employee of the City of Orlando, Orlando Housing, Authority, Greater Orlando Aviation Authority or Orlando Utilities Commission? Myself Relative No
If yes, list appropriate relative:Name:When YYYY:What Position:
N/A DAUGHTER IN LAW HALF SISTER SISTER-IN-LAW SPOUSE STEP SON
AUNT DAUGHTER MOTHER-IN-LAW MYSELF STEP BROTHER STEP SISTER
BROTHER-IN-LAW FATHER-IN-LAW MOTHER SISTER STEP DAUGHTER UNCLE
BROTHER FATHER NEPHEW SON STEP FATHER UNKNOWN RELATIONSHIP
COUSIN HALF BROTHER NIECE SON IN LAW STEP MOTHER

Question #2:
Are you or any of your relatives presently or formerly, directly or indirectly, employed by any person, firm or corporation having or proposing to have any contractual relation with or rendering, or  proposing or render services for any consideration to the City, Housing Authority, Aviation Authority or Utilities Commission? Myself Relative No
Do you or your relatives own an interest in such a firm or corporation? Yes No
If yes, state the relationship:When YYYY:Which Person, Firm or Corporation:


N/A DAUGHTER IN LAW HALF SISTER SISTER-IN-LAW SPOUSE STEP SON
AUNT DAUGHTER MOTHER-IN-LAW MYSELF STEP BROTHER STEP SISTER
BROTHER-IN-LAW FATHER-IN-LAW MOTHER SISTER STEP DAUGHTER UNCLE
BROTHER FATHER NEPHEW SON STEP FATHER UNKNOWN RELATIONSHIP
COUSIN HALF BROTHER NIECE SON IN LAW STEP MOTHER
For the purpose of this question, "crime" or "criminal charge" means a misdemeanor or felony (and does not include a mere traffic or parking citation).

Have you ever been convicted of a crime OR pled guilty to a criminal charge OR pled nolocontendere (no contest) to a criminal charge?
Yes No




If yes, what charge:Where:When YYYY:Disposition:
Convicted
Pled Guilty
Pled No Contest

Background Check Verification:The Florida Constitution, in section 5(a) of Article II, prohibits simultaneous "dual office holding." Service on most City of Orlando boards constitutes the holding of an "office" under Florida Law. If you were already serving on a Board Authority, or Commission for the City of Orlando or for another governmental agency, would you be willing to resign in order to accept the appointment you now seek?

Yes No

The City of Orlando may conduct a background check including a criminal history check. Your agreement below authorizes the City of Orlando to conduct such checks as it deems necessary.

Yes No

Responsibilities Agreement:I understand the responsibility associated with being a Board member, and I have adequate time to serve on the above Board(s)
Yes, I agree to the above statement
No, I disagree with the above statement

Final Agreement:I understand the importance of this Questionnaire and I attest to the validity of the information with which I have provided.
Yes, I agree to the above agreement
No, I disgree with the above statement


If you have any questions, please call the Office of the City Clerk (407) 246-2251.






How did you find out about the Advisory Boards? UNKNOWN
NOMINATING BOARD MEMBER
CITY EMPLOYEE
CITY'S INTERNET SITE
WORD OF MOUTH
FRIEND / NEIGHBOR
MAYOR / CITY COMMISSIONER
CITY BOARD BROCHURE
NEWSLETTER
NEIGHBORHOOD ASSOCIATION MEETING
OTHER