Gubernatorial Appointment Toolkit...
Transcript of Gubernatorial Appointment Toolkit...
Gubernatorial Appointment Toolkit2014-2015
The AIA Florida Citizen Architect Leadership Program: Gubernatorial Appointment Program (GAP) is an effort to assist placement of architects in positions of influence in our communities.
For more information conatct AIA Florida Headquarters at 850-222-7590.
AIA Citizen Architect Leadership Program:Gubernatorial Appointment Program (GAP)
In an effort to grow the influence of the architectural profession, AIA Florida has developed the Gubernatorial Appointment Program (GAP) to help place architects in positions of influence within our communities.
The state of Florida currently has greater than 900 appointed positions on various boards and committees around the state. These appointments are awarded by the governor’s office throughout the year as seats become vacant.
AIA Florida has identified more than 250 positions for which architects could provide key insight and leadership. These vary from state regulatory & code boards, community/regional development boards to local cultural and arts boards. AIA Florida’s mission is to position architects to lead the shaping of Florida’s future. To that end, it is vital that the profession be represented on these boards in order to provide leadership and guidance in all aspects of business that affect the built environment.
The following toolkit provides each component with all pertinent information regarding each appointed position in addition to an example application and links to the Governor’s appointment applications.
It is intended that interested parties will coordinate with AIA Florida to complete all submittal information. After reviewing the attached application as generated by the state of Florida, please submit your resume along with responses for application questions 16-19; as well as responses to questionnaire questions 17-30, to AIA Florida no later than Dec. 5, 2014 for review. Following the review and comment process, applicants will complete the full online application and questionnaire to submit to the Office of the Governor. AIA Florida will then have the opportunity to advocate for your appointment.
Table of Contents
Current Vacancies..................................................................................1
State of Florida Appointment Application................................................10
Questionnaire for Gubernatorial Appointments.......................................20
*SC= Senate Confirmation
Board Name Term SC* Appt Date Exp Date Incumbent Name Seat QualificationChildren's Trust Governing
Board of Miami-Dade County 4 Years No 7/18/2011 3/17/2014 Ms. Membiela, Roymi Seven appointed by the GovernorChildren's Trust Governing
Board of Miami-Dade County 4 Years No 7/18/2011 3/17/2014 Mrs. de Moya, Lileana Seven appointed by the Governor
Florida Greenways and Trails Council
2 Years No 10/18/2013 1/21/2014Mr. Diaz de Villegas,
RobertoThe Governor appoints two members representing the trail user community.
Southeast Volusia Hospital District
4 Years No 6/2/2011 3/31/2014 Mr. Heeb, Ferdinand
Governor appoints a resident of the City of Edgewater effective upon next
vacancy.Southeast Volusia Hospital
District 4 Years No 6/22/2011 3/31/2014 Mr. Smothers, HaroldGovernor appoints a resident of the City
of Oak Hill.
Acquisition and Restoration Council
4 Years No Vacant
The Governor shall appoint three members from scientific disciplines
related to land, water or environmental sciences.
Apalachee Regional Planning Council, Region Two 3 Years Yes Vacant Jackson County
Apalachee Regional Planning Council, Region Two
3 Years Yes Vacant
An elected school board member nominated by the Florida School Board
Association, appointed by the Governor.Baker County Development
Commission 4 Years No 8/23/2005 10/28/2008 Ms. Gore, Polly County Commission District 4Baker County Development
Commission 4 Years No 10/22/2005 10/21/2009 Ms. D'Ane, Gloriya Two members from the county at-large.Baker County Development
Commission 4 Years No 11/2/2005 11/1/2009 Mrs. Davis, Joyce County Commission District 5
State of FloridaGovernor of list of Board Committee Appointment
2014
*SC= Senate Confirmation
Baker County Development Commission 4 Years No 10/26/2006 10/13/2010 Mr. MANN, RONALD County Commission District 1
Baker County Development Commission 4 Years No 8/30/2013 10/22/2013 Mr. Gazes, Christopher Two members from the county at-large.
Baker County Development Commission 4 Years No Vacant County Commission District 2
Baker County Hospital Authority 4 Years No 10/25/2004 9/8/2008 Ms. Dedmon, Melba NA
Baker County Hospital Authority 4 Years No 10/25/2004 9/8/2008 Mrs. Dolan, Karen NA
Baker County Hospital Authority 4 Years No 4/4/2006 12/9/2009 Mr. McKendree, Glenn NA
Baker County Hospital Authority 4 Years No 4/4/2006 12/9/2009 Mr. Ferreira, Vincent NA
Baker County Hospital Authority 4 Years No 12/10/2006 12/9/2010 Mrs. Gnann, Debra NA
Biomedical Research Advisory Council
3 Years No 4/19/2010 1/10/2012 Mr. Wahlestedt, Claes
Governor shall appoint two members with expertise in the field of biomedical
research.
Biomedical Research Advisory Council
3 Years No 4/20/2010 1/10/2012 Dr. Weissbach, Herbert
Governor shall appoint two members with expertise in the field of biomedical
research.
Biomedical Research Advisory Council
3 Years No 2/27/2009 1/10/2012 Mr. Latimer, Albert
Governor shall appoint one member representing the general population of
the state.
Biomedical Research Advisory Council
3 Years No VacantGovernor shall appoint one member
from a research university in the state.
Board of Commissioners, North Broward Hospital District
4 Years No Vacant subdistrict #1
Board of Commissioners, South Broward Hospital District
4 Years No 7/17/2009 6/30/2011 Mr. Jones, Albert Member must reside in subdistrict #1
*SC= Senate Confirmation
Board of County Commissioners of Glades
County 4 Years No Vacant N/ABoard of Trustees, Florida A
and M University 5 Years Yes Vacant Six member appointed by the GovernorBoard of Trustees, Florida
Polytechnic University 4 Years Yes VacantOne member appointed by the
GovernorBoard of Trustees, Florida
School for the Deaf and the Blind 4 Years Yes 2/22/2010 11/13/2013 Ms. Rodriguez, Yolanda 5 Lay Members
Board of Trustees, Florida School for the Deaf and the
Blind 4 Years Yes 2/22/2010 11/20/2013 Ms. Ross, Carol 5 Lay MembersBoard of Trustees, Florida
School for the Deaf and the Blind 4 Years Yes Vacant 5 Lay Members
Board of Trustees, Florida Virtual School 4 Years No Vacant
Seven members appointed by the Governor.
Bradford County Development Authority 4 Years No 9/19/1997 7/24/2001 Mr. Johns, Charley Members from county-at-large.
Bradford County Development Authority 4 Years No 5/13/1998 11/29/2001 Dr. Berry, Virgil County Commission District 3
Bradford County Development Authority 4 Years No 9/6/2000 7/20/2004 Mr. Biggs, James Members from county-at-large.
Bradford County Development Authority 4 Years No 9/6/2000 9/5/2004 Mrs. Starling, Janet County Commission District 2
Bradford County Development Authority 4 Years No Vacant County Commission District 1
Bradford County Development Authority 4 Years No Vacant County Commission District 4
Bradford County Development Authority 4 Years No Vacant County Commission District 5
Cape Canaveral Hospital District, Brevard County 4 Years No 12/7/2007 8/19/2011 Mr. Fischer, Russell NA
*SC= Senate Confirmation
Cape Canaveral Hospital District, Brevard County 4 Years No 12/7/2007 8/19/2011 Mr. Anderson, John NACape Canaveral Hospital District, Brevard County 4 Years No 12/7/2007 8/19/2011 Mr. Ragland, Charles NACape Canaveral Hospital District, Brevard County 4 Years No 12/7/2007 8/19/2011 Dr. Ross, David NACape Canaveral Hospital District, Brevard County 4 Years No 12/7/2007 8/19/2011 Mrs. George, Judith NACape Canaveral Hospital District, Brevard County 4 Years No 12/7/2007 8/19/2011 Mrs. Teran, Monica NACape Canaveral Hospital District, Brevard County 4 Years No 9/24/2009 8/19/2013 Mr. Bray, Ronald NACape Canaveral Hospital District, Brevard County 4 Years No 9/24/2009 8/19/2013 Dr. Von Thron, Joseph NACape Canaveral Hospital District, Brevard County 4 Years No 9/24/2009 8/19/2013 Mr. Kabboord, John NACape Canaveral Hospital District, Brevard County 4 Years No 9/24/2009 8/19/2013 Ms. Schenck, Barbara NACape Canaveral Hospital District, Brevard County 4 Years No 9/24/2009 8/19/2013 Mrs. Lee, Rhonda NACape Canaveral Hospital District, Brevard County 4 Years No 9/24/2009 8/19/2013 Dr. Flom, Elena NA
Central Florida Regional Planning Council, Region Seven
3 Years Yes 4/13/2009 10/1/2010 Mrs. Tucker, Jacqueline Desoto County
Central Florida Regional Planning Council, Region Seven
3 Years Yes 4/23/2012 10/1/2013 Mr. Huddleston, Chester Hardee County
Central Florida Regional Planning Council, Region Seven
3 Years Yes 2/6/2013 10/1/2013 Mr. Goodman, Marshall Polk County
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant Highlands County
*SC= Senate Confirmation
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant Okeechobee County
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant Polk County
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant
A representative nominated by Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
Central Florida Regional Planning Council, Region Seven
3 Years Yes Vacant
An elected school board member nominated by the Florida School Boardd Association, appointed by the Governor.
Citrus County Hospital Board4 Years Yes Vacant NA
Citrus County Hospital Board4 Years Yes Vacant NA
Construction Industry Licensing Board 4 Years Yes 8/20/2013 10/31/2013 Mr. Del Vecchio, Paul Four General Contractors
Construction Industry Licensing Board 4 Years Yes 8/20/2013 10/31/2013
Mr. Dachepalli, Badarinath Two Lay Members
Construction Industry Licensing Board 4 Years Yes Vacant
Three Building or Residential Contractors, at least one of each.
District Board of Trustees, Chipola College 4 Years Yes 8/21/2007 5/31/2011 Mrs. Page, Jan Washington County
*SC= Senate Confirmation
District Board of Trustees, Chipola College 4 Years Yes 8/3/2009 5/31/2013 Mrs. Stuart, Virginia Jackson County
District Board of Trustees, Chipola College 4 Years Yes 8/3/2009 5/31/2013 Mr. Ryals, Daniel Calhoun County
District Board of Trustees, Chipola College 4 Years Yes 8/3/2009 5/31/2013 Dr. Bailey, Leisa Holmes County
District Board of Trustees, Florida Gateway College 4 Years Yes 6/4/2007 5/31/2010 Mrs. Wall, Harriet Dixie County
District Board of Trustees, Florida Gateway College 4 Years Yes 8/30/2007 5/31/2011 Mrs. Randolph, Athena Columbia County
District Board of Trustees, Florida Gateway College 4 Years Yes 8/30/2007 5/31/2011 Mr. Riherd, Thomas Union County
District Board of Trustees, Florida Gateway College 4 Years Yes 8/17/2009 5/31/2013 Mrs. Norris, Suzanne Columbia County
District Board of Trustees, Florida Gateway College 4 Years Yes 8/17/2009 5/31/2013 Mrs. Richardson, Julia Baker County
District Board of Trustees, Florida Gateway College 4 Years Yes 8/17/2009 5/31/2013 Ms. McInnis, Kathryn Dixie County
District Board of Trustees, Indian River State College 4 Years Yes 8/21/2007 5/31/2011 Mr. Bols, Werner Martin CountyDistrict Board of Trustees, Indian River State College 4 Years Yes 8/18/2009 5/31/2013 Ms. Rowley, Jane St. Lucie CountyDistrict Board of Trustees, Indian River State College 4 Years Yes 8/18/2009 5/31/2013 Mrs. Davis, Vicki Martin County
District Board of Trustees, Lake-Sumter State College 4 Years Yes 9/11/2007 5/31/2011 Dr. Kelly, Kenneth Sumter County
District Board of Trustees, Lake-Sumter State College 4 Years Yes 9/2/2009 5/31/2013 Mrs. Odom, Margo Lake County
District Board of Trustees, North Florida Community
College 4 Years Yes 8/30/2007 5/31/2010 Mr. Helvenston, Brantly Suwannee CountyDistrict Board of Trustees, North Florida Community
College 4 Years Yes 5/20/2009 5/31/2010 Dr. Brothers, William Suwannee County
*SC= Senate Confirmation
District Board of Trustees, North Florida Community
College 4 Years Yes Vacant Hamilton CountyDistrict Board of Trustees,
Northwest Florida State College 4 Years Yes 8/6/2007 5/31/2011 Mr. Pennington, Brian Okaloosa County
District Board of Trustees, Northwest Florida State
College 4 Years Yes 7/15/2009 5/31/2013 Mrs. Strauss, Mary Okaloosa CountyDistrict Board of Trustees,
Northwest Florida State College 4 Years Yes 7/15/2009 5/31/2013 Ms. Gillis, Rachel Walton County
District Board of Trustees, Northwest Florida State
College 4 Years Yes Vacant Okaloosa CountyDistrict Board of Trustees,
Northwest Florida State College 4 Years Yes Vacant Okaloosa County
District Board of Trustees, Palm Beach State College 4 Years Yes 7/15/2009 5/31/2013 Mr. Talley, David Palm Beach County
District Board of Trustees, Pasco-Hernando Community
College 4 Years Yes 6/4/2007 5/31/2010 Ms. Gavish, Jeanne Hernando CountyDistrict Board of Trustees,
Pasco-Hernando Community College 4 Years Yes 7/15/2009 5/31/2013 Mr. Di Rienzo, John Hernando County
District Board of Trustees, Pensacola State College 4 Years Yes 7/15/2009 5/31/2013 Mr. O'Connor, John Santa Rosa County
District Board of Trustees, Polk State College 4 Years Yes 8/26/2009 5/31/2013 Mrs. Martinez, Teresa NA
District Board of Trustees, Polk State College 4 Years Yes 8/26/2009 5/31/2013 Mr. Pinner, Ernest NA
District Board of Trustees, Santa Fe College 4 Years Yes 7/15/2009 5/31/2013 Dr. Jackson, Bessie Alachua County
*SC= Senate Confirmation
District Board of Trustees, Santa Fe College 4 Years Yes 7/15/2009 5/31/2013 Mr. McRae, Arley Bradford County
District Board of Trustees, Tallahassee Community College
4 Years Yes 9/15/2009 5/31/2013 Dr. Callen, Dana Leon County
District Board of Trustees, Tallahassee Community College
4 Years Yes 9/15/2009 5/31/2013 Mr. DeFoor, J. Allison Wakulla County
District Board of Trustees, Tallahassee Community College
4 Years Yes Vacant Gadsden County
East Central Florida Regional Planning Council, Region Six
3 Years Yes 3/18/2010 10/1/2012 Mr. Glover, Robert Brevard County
East Central Florida Regional Planning Council, Region Six
3 Years Yes 3/18/2010 10/1/2012 Mr. Lesman, John Orange County
East Central Florida Regional Planning Council, Region Six
3 Years Yes Vacant Lake County
East Central Florida Regional Planning Council, Region Six
3 Years Yes Vacant Osceola County
East Central Florida Regional Planning Council, Region Six
3 Years Yes Vacant Brevard County
East Central Florida Regional Planning Council, Region Six
3 Years Yes Vacant Volusia County
East Central Florida Regional Planning Council, Region Six
3 Years Yes VacantA representative of the Department of
Transportation. (Ex-officio member)
*SC= Senate Confirmation
East Central Florida Regional Planning Council, Region Six
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
East Central Florida Regional Planning Council, Region Six
3 Years Yes Vacant
An elected school board member nominated by the Florida School Boardd Association, appointed by the Governor.
Florida Building Code Administrators and Inspectors
Board 4 Years Yes Vacant Two members serving as an inspector.
Florida Building Commission4 Years Yes Vacant
Residential Contractor licensed to do business in Florida and actively engaged
in profession.Florida Commission on
Community Service 3 Years Yes Vacant NAAFlorida Commission on the
Status of Women 4 Years No 10/15/2008 9/30/2011 Ms. Maldonado, Alci Governor shall appoint 4 members.Florida Commission on the
Status of Women 4 Years No 2/1/2010 9/30/2013 Mrs. Wall, Barbara Governor shall appoint 4 members.Florida Commission on the
Status of Women 4 Years No Vacant Governor shall appoint 4 members.Florida Commission on the
Status of Women 4 Years No Vacant Governor shall appoint 4 members.
Florida Communities Trust4 Years Yes Vacant
Governor shall appoint a former elected official of a metropolitan municipal
government.Florida Council on Arts and
Culture 4 Years No 10/5/2010 12/31/2010 Ms. Wester, ElizabethSeven members appointed by the
Governor.Florida Council on Arts and
Culture 4 Years No 6/23/2008 12/31/2010 Mr. Judd, RobertSeven members appointed by the
Governor.Florida Council on Arts and
Culture 4 Years No 10/5/2010 12/31/2013 Mrs. Townsend, KathrynSeven members appointed by the
Governor.
*SC= Senate Confirmation
Florida Council on Arts and Culture 4 Years No 10/5/2010 12/31/2013
The Honorable Deratany, Timothy
Seven members appointed by the Governor.
Florida Council on Arts and Culture 4 Years No 10/5/2010 12/31/2013 Mr. Lochrie, Glenn
Seven members appointed by the Governor.
Florida Council on Arts and Culture 4 Years No Vacant
Seven members appointed by the Governor.
Florida Development Finance Corporation 4 Years Yes Vacant NA
Florida Development Finance Corporation 4 Years Yes Vacant
One of the directors shall be an economic development specialist.
Florida Major Performing Arts Center Task Force
1 Year No Vacant
The Governor shall appoint one member from among the cultural
community leadership.Florida Real Estate Appraisal
Board 4 Years Yes VacantTwo Licensed or Certified Residential
Real Estate Appraisers.
Florida Real Estate Appraisal Board
4 Years Yes Vacant
Two members of the general public who are not connected in any way with real
estate appraisal.
Florida Rehabilitation Council
3 Years No Vacant
At least one representative of a parent training and information center,
pursuant to s. 671 of the Individuals with Disabilities Education Act.
Florida Rehabilitation Council
3 Years No Vacant
At least one representative who is a director of a Vocational Rehabilitation Service Project for American Indians
with Disabilities under s. 121.
Florida Small Business Development Center Network
Statewide Advisory Board4 Years No Vacant Member from the private sector
Gilchrist County Housing Authority 4 Years No Vacant NA
*SC= Senate Confirmation
Governor's Mansion Commission 4 Years Yes 2/3/2011 9/30/2013 Mrs. Graham, Adele Governor's Appointment
Governor's Mansion Commission 4 Years Yes 2/3/2011 9/30/2013 Mrs. Aurell, Jane Governor's Appointment
Governor's Mansion Commission 4 Years Yes Vacant Governor's Appointment
Governor's Panel on Excellence in Long-Term Care
4 Years No VacantGovernor shall appoint a consumer
advocate for senior citizens.Hamilton County Development
Authority 4 Years No 10/8/2010 9/11/2013 Mr. Cloyd, JohnOne member shall represent County
Commission District 2Hamilton County Development
Authority 4 Years No VacantOne member shall represent County
Commission District 1Hamilton County Development
Authority 4 Years No Vacant Three members at-largeHamilton County Memorial
Hospital Board 4 Years No 10/19/2005 1/22/2008Mrs. Williams,
Jacqueline NAHamilton County Memorial
Hospital Board 4 Years No 10/19/2005 1/22/2009 Dr. Norris, W. Benjamin NAHamilton County Memorial
Hospital Board 4 Years No 2/16/2006 1/22/2010 Mrs. Tompkins, Amelia NAHamilton County Memorial
Hospital Board 4 Years No 2/16/2006 1/22/2010 Mrs. Daniels, Ida NAHamilton County Memorial
Hospital Board 4 Years No Vacant NA
Harbor Master for Port of Fort Pierce, Saint Lucie County
2 Years Yes 6/6/2005 4/4/2007 Mr. Porter, Jesse NAHernando County Housing
Authority 4 Years No Vacant NA
Higher Education Facilities Financing Authority
5 Years Yes Vacant
Five members appointed by the Gov including an empl or dir, etc, of an
institution of higher ed.
*SC= Senate Confirmation
Highlands County Housing Authority 4 Years No Vacant NA
Hillsborough County Civil Service Board 4 Years Yes Vacant NA
Indian River County Housing Authority 4 Years No Vacant NA
Indian River County Housing Authority 4 Years No Vacant NA
Investment Advisory Council4 Years Yes Vacant N/A
Metropolitan Planning Organization of Miami-Dade
County 4 Years No 3/11/2010 12/16/2013 Mrs. Hantman, PerlaGovernor appoints a school board
member.Metropolitan Planning
Organization of Miami-Dade County 4 Years No Vacant
Governor appoints an elected official from a municipality within the county.
Metropolitan Planning Organization of Miami-Dade
County 4 Years No Vacant
Governor appoints a person who does not hold an elected office & reside in
unincorp. area of county
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2010 Mr. Montgomery, James Columbia County
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2010 Mrs. Haas, Sandra Suwannee County
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2012 Mr. Eubank, F. Wesley Alachua County
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2012 Mrs. Thomas, Lorene Dixie County
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2012 Mr. Williams, Charles Hamilton County
*SC= Senate Confirmation
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2012 Mr. Williams, Michael Madison County
North Central Florida Regional Planning Council, Region 3
3 Years Yes 12/17/2009 10/1/2012 Mr. Smith, Andrew Union County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant Alachua County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant Alachua County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant Alachua County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant Bradford County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant Gilchrist County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant Taylor County
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant
A representative nominated by Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
North Central Florida Regional Planning Council, Region 3
3 Years Yes Vacant
An elected school board member nominated by the Florida School Board
Associationn, appointed by the Governor.
*SC= Senate Confirmation
Northeast Florida Regional Planning Council, Region Four
3 Years Yes 3/26/2009 10/1/2010 Mrs. Brown, Elaine Duval County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes 2/19/2010 10/1/2012 Mr. Register, Darryl Baker County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes 2/19/2010 10/1/2012 Mr. Sgroi, Robert Flagler County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes 2/19/2010 10/1/2012 Mr. Williams, Larry Nassau County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant St. Johns County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant Clay County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant St. Johns County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant Clay County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant Duval County
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant
A representative nominated by Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
*SC= Senate Confirmation
Northeast Florida Regional Planning Council, Region Four
3 Years Yes Vacant
An elected school board member nominated by the Florida School Board
Association, appointed by the Governor.
Participant Local Government Advisory Council
4 Years Yes Vacant
Council members have distinguished backgrounds in business, finance, and
public service.Public Swimming and Bathing
Facilities Advisory Review Board 4 Years No Vacant
Representative of the swimming pool industry.
Rehabilitation Council for the Blind
3 Years No VacantThe director of the division, who shall
be an ex officio member of the council.
School Board of Baker County4 Years No Vacant District 3
School Board of Highlands County 4 Years No Vacant District 5
School Board of Seminole County 2 Years No Vacant District 1
South Florida Regional Planning Council, Region Eleven
3 Years Yes 4/23/2012 10/1/2013 Mrs. Asseff, Patricia Broward County
South Florida Regional Planning Council, Region Eleven
3 Years Yes Vacant Broward County
South Florida Regional Planning Council, Region Eleven
3 Years Yes VacantA representative of the Department of
Transportation. (Ex-officio member)
South Florida Regional Planning Council, Region Eleven
3 Years Yes Vacant
A representative of the Department of Environmental Regulation. (Ex-officio
member)
*SC= Senate Confirmation
South Florida Regional Planning Council, Region Eleven
3 Years Yes Vacant
A representative nominated by Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
South Florida Regional Planning Council, Region Eleven
3 Years Yes Vacant
An elected school board member nominated by the Florida School Board
Association, appointed by the Governor.South Lake County Hospital District Board of Trustees 4 Years Yes 10/11/2007 7/5/2011 Mr. Drawdy, Rodney NA
South Lake County Hospital District Board of Trustees 4 Years Yes 10/11/2007 7/5/2011 Dr. Hari, Aashiv NA
South Lake County Hospital District Board of Trustees 4 Years Yes 4/23/2012 7/5/2013 Mr. Rountree, Paul NA
Southeast Volusia Hospital District 4 Years No 6/10/2009 3/31/2013 Mr. DeSimone, Thomas
Governor appoints a resident of the City of New Smyrna Beach.
Southeast Volusia Hospital District 4 Years No Vacant
Governor appoints a resident of the City of New Smyrna Beach.
Southwest Florida Regional Planning Council, Region Nine
3 Years Yes 5/13/2009 10/1/2011Mr. Mazzarantani,
George Sarasota County
Southwest Florida Regional Planning Council, Region Nine
3 Years Yes 4/23/2012 10/1/2013 Ms. Holquist, Laura Lee County
Southwest Florida Regional Planning Council, Region Nine
3 Years Yes Vacant Lee County
Southwest Florida Regional Planning Council, Region Nine
3 Years Yes Vacant Sarasota County
Southwest Florida Regional Planning Council, Region Nine
3 Years Yes Vacant
An elected school board member nominated by the FL Sch Bd Assn,
appointed by the Governor.
*SC= Senate Confirmation
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes 7/17/2007 10/1/2009 Other Bittner, Linda Pinellas County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes 4/23/2012 10/1/2012 Mrs. Vance, Kim Hillsborough County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes 6/21/2011 10/1/2012 Mr. Young, Earl Pasco County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes 4/23/2012 10/1/2013 Mr. Schock, Timothy Hillsborough County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes 2/1/2012 10/1/2013 Ms. Todd, Barbara Pinellas County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant Hillsborough County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant Manatee County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant Pinellas County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant Position Not Needed - Pinellas County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant Pasco County
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant Hillsborough County
*SC= Senate Confirmation
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
Tampa Bay Regional Planning Council, Region Eight
3 Years Yes Vacant
An elected school board member nominated by the Florida School Board
Association, appointed by the Governor.
Tampa Port Authority4 Years Yes 1/27/2010 11/25/2013 Mr. Shipp, Lawrence
Representative of Seat Three appointed by the Governor.
Technological Research and Development Authority,
Brevard County 4 Years No Vacant NATechnological Research and
Development Authority, Brevard County 4 Years No Vacant NA
Technological Research and Development Authority,
Brevard County 4 Years No Vacant NATechnological Research and
Development Authority, Brevard County 4 Years No Vacant NA
Technological Research and Development Authority,
Brevard County 4 Years No Vacant NA
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes 3/26/2009 10/1/2010 Mr. Davis, Michael Palm Beach County
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes 4/23/2012 10/1/2013 Mr. Stork, Robert Indian River County
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes 4/23/2012 10/1/2013 Mr. Sachs, Peter Palm Beach County
*SC= Senate Confirmation
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant Palm Beach County
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant Palm Beach County
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant St. Lucie County
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant
A representative of the appropriate water management district or districts.
(Ex-officio member)
Treasure Coast Regional Planning Council, Region Ten
3 Years Yes Vacant
An elected school board member nominated by the Florida School Board
Association, appointed by the Governor.
West Florida Regional Planning Council, Region One
Pleasure of the
Governor Yes Vacant Walton County
West Florida Regional Planning Council, Region One
Pleasure of the
Governor Yes Vacant Okaloosa County
*SC= Senate Confirmation
West Florida Regional Planning Council, Region One
Pleasure of the
Governor Yes Vacant
An elected school board member nominated by the FL Sch Bd Assn,
appointed by the Governor.
West Orange Airport Authority4 Years No 7/26/2010 9/26/2011 Ms. Dupee, Ann
Three members appointed by the Governor.
West Orange Airport Authority4 Years No 7/26/2010 9/26/2011 Mr. Welch, Jeffrey
Three members appointed by the Governor.
West Orange Airport Authority4 Years No 7/26/2010 9/26/2013 Mr. Tua, Feliberto
Three members appointed by the Governor.
Withlacoochee Regional Planning Council, Region Five
3 Years Yes 7/13/2007 10/1/2009 Mr. Kelly, Edward Marion County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes 11/15/2007 10/1/2010 Mr. Abshier, R. Edward Marion County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes 10/1/2010 Mrs. Hanson, Martha Marion County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes Vacant Citrus County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes Vacant Hernando County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes Vacant Levy County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes Vacant Sumter County
Withlacoochee Regional Planning Council, Region Five
3 Years Yes Vacant
An elected school board member nominated by the FL Sch Bd Assn,
appointed by the Governor.
State of Florida Gubernatorial Appointments Office Contact: 850 / 717-9243 850 / 921-0733 (fax) [email protected] The Appointments Office supports the Governor in meeting his major obligation to appoint qualified, representative and appropriate people to a large number of important leadership roles throughout the State. Board and Commission Vacancies AIA Florida Appointment Spreadsheet
Action: Fillout the application at the following link: Gubernatorial Appointments Questionnaire Example of application: The information from this questionnaire will be used by the Governor’s office and, where applicable, The Florida Senate in considering action on your confirmation. The questionnaire MUST BE COMPLETED IN FULL. Answer "none" or "not applicable" where appropriate. 1- General
Title * First Name *
Middle / Maiden Last Name *
Email Address Cell Phone
Race * Gender *
Fax # Do you have a disability? If “Yes” list * Yes No
Addresses
Specify the preferred mailing address * Business Residential
2- Residence
Street * City *
State * County *
Zip / Postal Code * Phone Number
3- Business
Office # Street
City State
Zip / Postal Code Phone Number
4- A. List all your places of residence for the last ten (10) years.
Address City & State Start Date End Date Action
Insert
B. List all your former and current residences outside of Florida that you have maintained at any time during adulthood.
Address City & State Start Date End Date Action
Insert
5- Date of Birth * Place of Birth *
6- Driver License Number Issuing State
7- Social Security Number *
8- Have you ever used or been known by any other legal name? If “Yes” list * 9- A. Are you a United States citizen? If “No” list
Yes No Yes No
B. If you are a naturalized citizen, date of naturalization
10- Since what year have you been a continuous resident of Florida?
11- Vote
Are you a registered Florida voter? If “Yes” list * Yes No
County of registration Current party affiliation
12- A. High School Year Graduated
B. List all postsecondary educational institutions attended
Name & Location Start Date End Date Certificates / Degrees
Received
Action
Insert
13- Are you or have you ever been a member of the armed forces of the United States? If “Yes” list * Yes No
A. Date of service B. Branch or component
C. Date & Type of Discharge
14- Concerning your current employer and for all of your employment during the last ten years, list your employer’s name, business address, type of business,
occupation or job title, and period(s) of employment *
Employer's Name & Address Type of Business Occupation / Job Title Start Date End Date Action
Insert
15- Have you ever been employed by any state, district, or local governmental agency in Florida? If “Yes” list *
Yes No
Position Employing Agency Start Date End Date Action
Insert
16- A. State your experiences and interests or elements of your personal
history that qualify you for this appointment
B. Have you received any degree(s), professional certification(s), or
designations(s) related to the subject matter of this appointment? If “Yes” list
Yes No
C. Have you received any awards or recognitions relating to the subject matter
of this appointment? If “Yes” list
D. Identify all association memberships and association offices held by you that
relate to this appointment
Yes No
17- Do you currently hold an office or position (appointive, civil service, or other) with the federal or any foreign government? If “Yes” list *
Yes No
18- Have you previously been appointed to any office that required confirmation by the Florida Senate? If “Yes” list
Yes No
Title of Office Term of Appointment Confirmation Results Action
Insert
19- A. Have you ever been elected or appointed to any public office in this state? If “Yes” list * Yes No
Office Title Date of Election or
Appointment
Term of Office Level of Government (city, county,
district, state, federal)
Action
Insert
B. If your service was on an appointed board(s), committee(s), or council(s) *
1- How frequently were meetings scheduled
2- If you missed any of the regularly scheduled meetings, state the number of meetings you attended, the number you missed, and the reasons(s) for your
absence(s)
Meetings Attended Meetings Missed Reason for Absence Action
Insert
20- Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, regulation, or ordinance? (Exclude traffic
violations for which a fine or civil penalty of $150 or less was paid.) If “Yes” list *
Yes No
Date Place Nature Disposition Action
Insert
21- Has probable cause ever been found that you were in violation of the Code of Ethics for Public Officers and Employees, Part III, Chapter 112, F.S.? If “Yes”
list *
Yes No
Date Nature of Violation Disposition Action
Insert
22- Have you ever been suspended from any office by the Governor of the State of Florida? If “Yes” list * Yes No
Title of Office Reason for Suspension
Date of Suspension Result
23- Have you ever been refused a fidelity, surety, performance, or other bond? If “Yes” list * Yes No
24- Have you held or do you hold an occupational or professional license or certificate in the State of Florida? * Yes No
If “Yes”, provide the title and number, original issue date, and issuing authority. If any disciplinary action (fine, probation, suspension,
revocation, disbarment) has ever been taken against you by the issuing authority, state the type and date of the action taken
License / Certificate Title & Number Original Issue Date Issuing Authority Disciplinary Action Action
Insert
25- Have you ever been a registered lobbyist or have you lobbied at any level of government at any time during the past five (5) years? * Yes No
A. Did you receive any compensation other than reimbursement for expenses? Yes No
B. Name of agency or entity you lobbied and the principal(s) you represented
Agency Lobbies Principal Represented Action
26- If required by law or administrative rule, will you file financial disclosure statements? Yes No
27- A. Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or other direct dealings during the last four (4) years
with any state or local governmental agency in Florida, including the office or agency to which you have been appointed or are seeking appointment? If “Yes”
list *
Yes No
Name of Business Your Relationship to Business Business Relationship to Agency Action
Insert
B. Have members of your immediate family (spouse, child, parents(s), siblings(s)), or businesses of which members of your immediate family have been owners,
officers, or employees, held any contractual or other direct dealings during the last four (4) years with any state or local governmental agency in Florida,
including the office or agency to which you have been appointed or are seeking appointment? If “Yes” list *
Yes No
Name of Business Family Member's Relationship to You Family Member's
Relationship to Business
Business Relationship to Agency Action
Insert
28- List three persons who have known you well within the past five (5) years. Include a current, complete address and telephone number. Exclude your relatives
and members of the Florida Senate.
Name Mailing Address Zip Code Phone Number Action
Insert
29- Name any business, professional, occupational, civic, or fraternal organizations(s) of which you are now a member, or of which you have been a member
during the past five (5) years, the organization address(es), and date(s) of your membership(s)
Name Mailing Address Office(s) Held & Term Date of Membership Action
Insert
30- Do you know of any reason why you will not be able to attend fully to the duties of the office or position to which you have been or will be appointed? If “Yes”
list * Yes No
31- Are you now, or in the past three years have you been, a member of any club or organization that, to your knowledge, in practice or policy, restricts
membership or restricted membership during the time that you belonged on the basis of race, religion, national origin, or gender? If so, detail the name and
nature of the club(s) or organization(s), relevant policies and practices, and state whether you intend to continue as a member if you appointed by the Governor?
If “Yes” list Yes No
You can apply for up to 5 board seats per application.
Functional Category * All
Board Name *
Board Description
Seat Qualification *
Are you applying for reappointment ? Yes No
For Category For Board
For Seat
Add
Functional Category Board Name Seats Seat Qualification Reappointment Action
Resume
Please upload your
resume /CV
Only [doc, docx, pdf] files
I understand that any appointment tendered to me will be contingent upon the results of a background investigation, and I am aware that
withholding information or making false statements on this application may be the basis for non-appointment by the Executive Office of the
Governor. I agree to these conditions, and under the penalties of perjury I declare that I have read the foregoing application and that the facts stated
in it are true, correct, and complete to the best of my knowledge and belief. *
As a general matter, applications for all positions within state Government are public records, which may be viewed by anyone upon request.
However, there are some exemptions from the public records law for identifying information relating to past and present law enforcement officers
and their families, victims of certain crimes, etc. If you believe an exemption from the public records law applies to portions of your application,
please check this box.
First Name * Last Name *
If you need additional guidance as to the applicability of any public records law exemption to your situation, please contact the Office of the Attorney
General.
Office of the Attorney General
PL-01, The Capitol
Tallahassee, Florida 32399
(850) 245-0158
Preview
Follow-up with a written letter to the following Mailing Address Governor’s Appointments Office The Capitol Building Lower Level, Suite LL-09 Tallahassee FL 32399-0001 Recent Appointments
QUESTIONNAIRE for
GUBERNATORIAL APPOINTMENTS
Please Return To: 400 South Monroe Street
Capitol Building, Suite LL-09 Tallahassee, Florida 32399
1 Revised 11/2011
FOR THE GOVERNOR’S APPOINTMENTS OFFICE
The information from this page has been requested and will be used exclusively by the GOVERNOR’S OFFICE. Please type or use black ink.
1. Board of Interest: ___________________________________________________________________________
2. Seat of Interest: ___________________________________________________________________________
3. Current Employer and Occupation: ____________________________________________________
4. Are you applying for reappointment: Yes No
5. *Do you have a disability? Yes No If “Yes”, please describe your disability that would qualify you for this appointment, if applicable.
6. *Sex: Male Female
7. *Race: White Native-American/Alaskan Native Hispanic-American Asian/Pacific Islander African-American
8. Are you now, or in the past three years have you been, a member of any club or organization that, to your knowledge, in practice or policy, restricts membership or restricted membership during the time that you belonged on the basis of race, religion, national origin, or gender? If so, detail the name and nature of the club(s) or organization(s), relevant policies and practices, and state whether you intend to continue as a member if you appointed by the Governor. If yes, please describe. Yes No
Email address____________________________________________________________________________
Cellular Telephone Number_________________________________________________________________
__________________________________ Applicant’s Name, including name commonly used (Please print)
* This information will be used to provide demographic statistics and is not requested for the purpose of discriminating on any basis.
2 Revised 11/2011
QUESTIONNAIRE FOR GUBERNATORIAL APPOINTMENTS
The information from this questionnaire will be used by the Governor’s office and, where applicable, The Florida Senate in considering action on your confirmation. The questionnaire MUST BE COMPLETED IN FULL. Answer “none” or “not applicable” where appropriate. Please type or print in black ink.
_______________________________
Date Completed
1. Name: ______________________________________________________________________________________________ MR./MRS./MS./DR. LAST FIRST MIDDLE/MAIDEN
2. Business Address: _____________________________________________________________________________________ STREET OFFICE # CITY
____________________________________________________________________________________________________ POST OFFICE BOX STATE ZIP CODE AREA CODE/PHONE NUMBER
3. Residence Address: ____________________________________________________________________________________ STREET CITY COUNTY
____________________________________________________________________________________________________ POST OFFICE BOX STATE ZIP CODE AREA CODE/PHONE NUMBER
Specify the preferred mailing address: Business Residence Fax # ___________________
(optional )
4. A. List all your places of residence for the last ten (10) years.
ADDRESS CITY & STATE FROM TO
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B. List all your former and current residences outside of Florida that you have maintained at any time during adulthood.
ADDRESS CITY & STATE FROM TO
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
5. Date of Birth: _______________________________ Place of Birth: _________________________________________
6. Social Security Number: _______________________________________________________________________________
7. Driver License Number: _________________________________________ Issuing State: _________________________
3 Revised 11/2011
8. Have you ever used or been known by any other legal name? Yes No If “Yes,” list and explain.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
9. Are you a United States citizen? Yes No If “No” explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If you are a naturalized citizen, date of naturalization: _________________________________________________________
10. Since what year have you been a continuous resident of Florida? ________________________________________________
11. Are you a registered Florida voter? Yes No If “Yes” list:
A. County of registration: _______________________ B. Current party affiliation: ____________________________
12. Education
A. High School: ____________________________________________________ Year Graduated: ______________ (NAME AND LOCATION)
B. List all postsecondary educational institutions attended: NAME & LOCATION DATES ATTENDED CERTIFICATES/DEGREES RECEIVED
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
13. Are you or have you ever been a member of the armed forces of the United States? Yes No If “Yes” list:
A. Dates of service: __________________________________________________________________________________
B. Branch or component: ______________________________________________________________________________
C. Date & type of discharge: ___________________________________________________________________________
14. Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, regulation, or ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less was paid.) If “Yes” give details:
DATE PLACE NATURE DISPOSITION
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
4 Revised 11/2011
15. Concerning your current employer and for all of your employment during the last ten years, list your employer’s name, business address, type of business, occupation or job title, and period(s) of employment.
EMPLOYER’S NAME & ADDRESS TYPE OF BUSINESS OCCUPATION/JOB TITLE PERIOD OF EMPLOYMENT
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
16. Have you ever been employed by any state, district, or local governmental agency in Florida? Yes No If “Yes”, identify the position(s), the name(s) of the employing agency, and the period(s) of employment:
POSITION EMPLOYING AGENCY PERIOD OF EMPLOYMENT
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
17. A. State your experiences and interests or elements of your personal history that qualify you for this appointment.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B. Have you received any degree(s), professional certification(s), or designations(s) related to the subject matter of this appointment? Yes No If “Yes”, list:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
C. Have you received any awards or recognitions relating to the subject matter of this appointment? Yes No If “Yes”, list:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
5 Revised 11/2011
D. Identify all association memberships and association offices held by you that relate to this appointment: ________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
18. Do you currently hold an office or position (appointive, civil service, or other) with the federal or any foreign government? Yes No If “Yes”, list:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
19. A. Have you ever been elected or appointed to any public office in this state? Yes No If “Yes”, state the office title, date of election or appointment, term of office, and level of government (city, county, district, state, federal):
OFFICE TITLE DATE OF ELECTION OR APPOINTMENT TERM OF OFFICE LEVEL OF GOVERNMENT
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B. If your service was on an appointed board(s), committee(s), or council(s):
(1) How frequently were meetings scheduled: _________________________________________________________
(2) If you missed any of the regularly scheduled meetings, state the number of meetings you attended, the number you missed, and the reasons(s) for your absence(s).
MEETINGS ATTENDED MEETINGS MISSED REASON FOR ABSENCE
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
20. Has probable cause ever been found that you were in violation of the Code of Ethics for Public Officers and Employees, Part III, Chapter 112, F.S.? Yes No If “Yes”, give details:
DATE NATURE OF VIOLATION DISPOSITION
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
21. Have you ever been suspended from any office by the Governor of the State of Florida? Yes No If “Yes”, list:
A. Title of office: ____________________________ C. Reason for suspension: _______________________________
B. Date of suspension: ________________________ D. Result: Reinstated Removed Resigned
6 Revised 11/2011
22. Have you previously been appointed to any office that required confirmation by the Florida Senate? Yes No If “Yes”, list:
A. Title of Office: ___________________________________________________________________________________
B. Term of Appointment: _____________________________________________________________________________
C. Confirmation results: ______________________________________________________________________________
23. Have you ever been refused a fidelity, surety, performance, or other bond? Yes No If “Yes”, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
24. Have you held or do you hold an occupational or professional license or certificate in the State of Florida? Yes No If “Yes”, provide the title and number, original issue date, and issuing authority. If any disciplinary action (fine, probation,
suspension, revocation, disbarment) has ever been taken against you by the issuing authority, state the type and date of the action taken:
LICENSE/CERTIFICATE ORIGINAL
TITLE & NUMBER ISSUE DATE ISSUING AUTHORITY DISCIPLINARY ACTION/DATE
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
25. A. Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or other direct dealings during the last four (4) years with any state or local governmental agency in Florida, including the office or agency to which you have been appointed or are seeking appointment? Yes No If “Yes”, explain:
NAME OF BUSINESS YOUR RELATIONSHIP TO BUSINESS BUSINESS’ RELATIONSHIP TO AGENCY
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B. Have members of your immediate family (spouse, child, parents(s), siblings(s)), or businesses of which members of your immediate family have been owners, officers, or employees, held any contractual or other direct dealings during the last four (4) years with any state or local governmental agency in Florida, including the office or agency to which you have been appointed or are seeking appointment? Yes No If “Yes”, explain:
FAMILY MEMBER’S FAMILY MEMBER’S BUSINESS’ RELATIONSHIP
NAME OF BUSINESS RELATIONSHIP TO YOU RELATIONSHIP TO BUSINESS TO AGENCY
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
26. Have you ever been a registered lobbyist or have you lobbied at any level of government at any time during the past five (5) years? Yes No
A. Did you receive any compensation other than reimbursement for expenses? Yes No
B. Name of agency or entity you lobbied and the principal(s) you represented:
AGENCY LOBBIED PRINCIPAL REPRESENTED
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
7 Revised 11/2011
27. List three persons who have known you well within the past five (5) years. Include a current, complete address and telephone number. Exclude your relatives and members of the Florida Senate.
NAME MAILING ADDRESS ZIP CODE AREA CODE/PHONE NUMBER
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
28. Name any business, professional, occupational, civic, or fraternal organizations(s) of which you are now a member, or of which you have been a member during the past five (5) years, the organization address(es), and date(s) of your membership(s).
NAME MAILING ADDRESS OFFICE(S) HELD & TERM DATE(S) OF MEMBERSHIP
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
29. Do you know of any reason why you will not be able to attend fully to the duties of the office or position to which you have been or will be appointed? Yes No If “Yes”, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
30. If required by law or administrative rule, will you file financial disclosure statements? Yes No
8 Revised 11/2011
CERTIFICATION
STATE OF FLORIDA, COUNTY OF Before me, the undersigned Notary Public of Florida, personally appeared _____________________________________, who, after being duty sworn, say: (1) that he/she has carefully and personally prepared or read the answers to the foregoing questions; (2) that the information contained in said answers is complete and true; and (3) that he/she will, as an appointee, fully support the Constitutions of the United States and of the State of Florida.
___________________________________________
Signature of Applicant-Affiant
Sworn to and subscribed before me
this____________ day of ______________, 20___. ___________________________________________
Signature of Notary Public-State of Florida
___________________________________________
(Print, Type, or Stamp Commissioned Name of Notary Public)
My commission expires: ________________________
Personally Known OR Produced Identification
Type of Identification Produced _______________________________________________
(seal)
9 Revised 11/2011
MEMORANDUM
AS A GENERAL MATTER, APPLICATIONS FOR ALL POSITIONS WITHIN STATE GOVERNMENT ARE PUBLIC RECORDS, WHICH MAY BE VIEWED BY ANYONE UPON REQUEST. HOWEVER, THERE ARE SOME EXEMPIONS FROM THE PUBLIC RECORDS LAW FOR IDENTIFYING INFORMATION RELATING TO PAST AND PRESENT LAW ENFORCEMENT OFFICERS AND THEIR FAMILIES, VICTIMS OF CERTAIN CRIMES, ETC…IF YOU BELIEVE AN EXEMPTION FROM THE PUBLIC RECORDS LAW APPLIES TO YOUR SUBMISSION, PLEASE CHECK THIS BOX.
□ Yes, I assert that identifying information
provided in this application should be
excluded from inspection under Public
Records Law. Please indicate what
section of Florida Statutes provides this
in your particular situation.
__________________________________
IF YOU NEED ADDITIONAL GUIDANCE AS TO THE APPLICABILITY OF ANY PUBLIC RECORDS LAW EXEMPTION TO YOUR SITUATION, PLEASE CONTACT THE OFFICE OF THE ATTORNEY GENERAL.
The Office of the Attorney General
PL-01, The Capitol
Tallahassee, Florida 32399
(850) 245-0158