Application for City Council Appointments to Boards, Authorities, and Commissions

This application will be utilized in considering you for appointment to a City Council board, authority or commission. Pursuant to Florida Statutes, Chapter 119, all informatioin provided on or with this form becomes a public record and is subject to disclosure, unless otherwise exempted by law.

Required fields are marked with a red asterisk *
Completed applications will be kept on file for a period of one (1) year from the date received in the Office of the City Clerk
It is necessary to contact a member of Council to obtain a nomination in order to be placed on the ballot for consideration. Please go to this link for Council Member contact information.
If you have any questions contact: Office of the City Clerk, P.O. Box 12910, Pensacola, FL 32521, (850) 435-1606
The PDF version of this form is available at this link

THANK YOU FOR YOUR WILLINGNESS TO SERVE

Personal Information

Name *

Home Address *

Business Address *

Preferred Contact Phone Number(s) *

Email *

This information will be used only to notify you of board openings and other city news items.

Details

Are you a resident of the City? *

If yes, which district?

If yes, how long?

Do you own property within the City limits? *

Are you a registered voter in the City of Pensacola? *

Board(s) of interest *

Please list the reasons for your interest in this position. *

Do you currently serve on a City board, authority, or commission? *

If yes, please answer the next question.

If yes, which board?

Do you now hold public office? *

If yes, please answer the next question.

If so, what is the office?

Dual Office Holding *

The Florida Constitution, in section 5 (a) of Article II, prohibits simultaneous “dual office holding”. If you were already serving on a board, authority, or commission for the City of Pensacola or for another governmental agency, would you be willing to resign in order to accept the appointment you now seek?

Diversity

In order to encourage diversity in selections of members of government committees, the following information is required by Florida Statute 760.80 for some committees. Describe yourself within the categories below.

Race *

Gender *

Physically Disabled *

Acknowledgement

I hereby certify that the statements and answers provided are true and accurate. I understand that any false statements may be cause for removal from a board or committee if appointed.

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	Committee of the Whole Meeting			City Council Meeting	Mayor's Urban Redevelopment Advisory Committee
27	28	29	30	31	1	2
	Memorial Day

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Application for City Council Appointments to Boards, Authorities, and Commissions

May 2012