City of Deltona

Citizen Board/Committee Application

Name of Board/Committee

Personal Information Name

Address
City State Zip
# Years District

Phone Email Address

Are you a registered voter? Yes No

Employer # Years
Address
Phone Position
Summarize your work experience

Education

School	Years	Degree

Volunteer, Civic, Professional, & Other Activities

List any volunteer service organizations, clubs, or professional societies you are a member of and give the positions or titles you have held.
Have you ever served on a committee or advisory board? If so, give the details, including any positions held.
Have you ever held public office? If so, give the details, including offices involved, whether elected or appointed, and the length of service.

Reasons For Serving

Describe any additional knowledge, skill, education, or experience you have, which would assist you in the duties of this Board/Committee.
Explain why you want to serve on this Board/Committee, and include any potential contribution you selection would bring.

Miscellaneous

Potential conflict of interest: Do you do business, or are you engaged in the management of any business enterprise that has a financial interest with the City of Deltona? Please give details, including the name of the enterprise, the nature of the business, and the position you hold.
Have you ever been convicted for violation of any federal, state, county, or municipal law, regulation, or ordinance? If so, give details. Do not include traffic violations or fines of $100 or less that were imposed, unless it also included a jail sentence.

References List names, addresses, and telephone numbers of at least three persons who are in a position to comment on your qualifications and of whom inquiry may be made by the City of Deltona.

Additional Information or Comments

I declare the foregoing facts to be true, correct, and complete.

Name Date (MM/DD/YY)

Please note that the City Clerkﾒs Office keeps applications active for 6 months from the date of receipt if you are not chosen to fill the Board/Committee vacancy. If within that 6 months you wish to be considered for another Board/Committee vacancy other than the Board originally applied for, you must contact the City Clerkﾒs Office at (386) 561-2100 and request your application be pulled for consideration. After 6 months, a new application must be submitted.

2345 Providence Blvd. Deltona, FL 32725 Phone: (386) 878-8100 Fax: (386) 878-8501
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