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Gubernatorial Appointment Toolkit 2014-2015 e 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.

Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

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Page 1: Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

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.

Page 2: Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

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.

Page 3: Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

Table of Contents

Current Vacancies..................................................................................1

State of Florida Appointment Application................................................10

Questionnaire for Gubernatorial Appointments.......................................20

Page 4: Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

*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

Page 5: Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

*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

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*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

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*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

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*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

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*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

Page 10: Gubernatorial Appointment Toolkit 2014-2015aiafla.org/upload_documents/GAPToolKitwithLinktoList.pdf · Gubernatorial Appointment Toolkit 2014-2015 The AIA Florida Citizen Architect

*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

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*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)

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*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.

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*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

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*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.

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*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

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*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.

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*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.

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*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)

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*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.

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*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

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*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

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*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

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*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.

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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

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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 *

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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 *

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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

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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

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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 *

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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

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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

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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

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QUESTIONNAIRE for

GUBERNATORIAL APPOINTMENTS

Please Return To: 400 South Monroe Street

Capitol Building, Suite LL-09 Tallahassee, Florida 32399

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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.

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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: _________________________

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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

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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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:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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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

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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

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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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

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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)

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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