BOARD OF INTEREST:
1. Name:
3. Business Address:
4. Residence Address:
Please Note: The following information will be used to satisfy Equal Opportunity
reporting requirements.
5. Sex:
6. Race:
Please Note: Response to the following question is optional.
7. Are you a person with a disability?
If yes, please explain the nature of your disability:
9. Have you ever been convicted of any felony or misdemeanor offense?
11. Do you currently serve on any board/council/committee/authority in the State of Florida?
If yes, list name of board
13. Education:
B. List all post secondary educational institutions attended:
If yes, list their name, relationship and office:
If yes, please list below. If any disciplinary action
has been taken, please indicate the date and type of action taken.Please include the number of your license or certificate.
16. State your experience and interests or elements of your personal history
that qualify you for appointment:
If yes, please explain:
If yes, please list below.
19. Please list three persons who have known you well within the past five
(5) years. Include a current and complete address, phone number and the capacity in which
they have known you. Please list only those persons who have given their consent to be
used as a reference/
20. Name any business, professional, civic or fraternal organizations of
which you are a member, and the dates of your memberships.
21. Do you or your firm / business present variances or special use permits before the
Land Use Hearing Officer?
22. If yes, how often?
THESE CANNOT BE SUBMITTED ELECTRONICALLY AS ORIGINAL SIGNATURE IS REQUIRED.
Anti-Bullying Advisory Committee
Child Care Facilities Advisory Board
Child Care Licensing Hearing Officers
Children's Services Advisory Board
Family Child Care Home Advisory Board
Parks Recreation and Conservation Board
Public Library Board
Early Learning Coalition .
AS A MEMBER OF THE FOLLOWING BOARDS, YOU WILL BE REQUIRED AS A “LOCAL OFFICER” TO FILE A FINANCIAL DISCLOSURE FORM 1, WITHIN 30 DAYS OF APPOINTMENT AS WELL AS ANNUALLY THEREAFTER. Forms can be found on the Commission on Ethics website at www.ethics.state.fl.us under forms.
Arts Council
Building Board of Adjustment
Appeals & Examiners
Code Enforcement Board
Code Enforcement Special Magistrates
Electrical Board of Adjustment
Appeals & Examiners
Gas Board of Adjustment
Hillsborough Area Regional Transit Authority
Hospital Authority
Human Relations Board
Industrial Development Authority
Land Use Appeals Board
Mechanical Board of Adjustment
Nuisance Abatement Board
Planning Commission
Plumbing Board of Adjustment
Appeals & Examiners
Tampa Sports Authority.
Mail to:
To submit the completed form, deliver it to: To submit the completed form, deliver it to:
Deliver/Mail to:
Scan and e-mail to: finleyl@hillsboroughcounty.org
For this form to be valid, please sign below.
PRINT NAME
SIGNATURE
DATE
E-MAIL ADDRESS:
FAX NUMBER:
Click here to output Printer-friendly form with your
information included. You must then sign this form and follow submittal instructions above.
