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Advisory Board
Application for Appointment

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The information from this application will be used by the Orange County Board of County Commissioners when considering appointments to advisory boards, authorities and commissions.
* = Required Fields

Section 1

Title

Mr. Ms.

First Name*

Middle Name/Initial

Last Name*

Email Address

Telephone

Home*


Work	Ext

Are you a Registered Voter?*

Yes No

Advisory Board(s) of Interest*
Please select up to 3 different boards.

NOTE: You are not required to answer the following questions. However, they are asked in order that the boards, commissions and authorities to which the Board of County Commissioners makes appointments may be representative of the demographics of the citizens of Orange County.

Are you of Hispanic origin?

Race

Gender

Disabled?

Date of Birth

Section 2
Home Address*	Street Number* Street Direction (N,S,E,W) Street Name* Street Type Street Suffix (N,S,E,W) Suite City* State: FL Zip*
Mail Address	If same as home address check this box P.O. Box Street Number Street Direction (N,S,E,W) Street Name Street Type Street Suffix (N,S,E,W) Suite City State Zip
Business Address	P.O. Box Street Number Street Direction (N,S,E,W) Street Name Street Type Street Suffix (N,S,E,W) Suite City State: FL Zip
Place of Employment
Job Title	Years Employed
Educational Information:	School Name Degree Earned
Educational Information:	School Name Degree Earned

Section 3
If you have ever held any Professional or Occupational Licenses, or Registration or Certification please provide the title, issue date, and issuing authority. If any disciplinary action has been taken, please state the type and date of the action taken.
Licenses and Certificates	Title License/Certificate Issuing Authority Issue Date(mm/dd/yy): Disciplinary Action Disciplinary Action Dates(mm/dd/yy): From To
Licenses and Certificates	Title License/Certificate Issuing Authority Issue Date(mm/dd/yy): Disciplinary Action Disciplinary Action Dates(mm/dd/yy): From To
	Please briefly state your experience, interests, or elements of your personal history that you think qualify you for appointment to the board(s) you have chosen. (Maximum 2000 characters)*
	Have you, members of your immediate family, or businesses of which you or members of your immediate family have been an owner, officer or employee, held any contractual or other dealings during the last three years with any Orange County Government agency, including the board to which you seek appointment? Yes No If "Yes", please explain briefly (Maximum 2000 characters):
Please list three (3) persons who have known you well within the past five (5) years. Include telephone number where they can be reached during the day, and the capacity in which they have known you.
Reference 1	First Name Last Name Telephone Capacity/Relationship
Reference 2	First Name Last Name Telephone Capacity/Relationship
Reference 3	First Name Last Name Telephone Capacity/Relationship
Name any business, professional, civic or fraternal organizations of which you are a member, and the dates of your membership.
Membership 1	Organization Membership Dates: From To
Membership 2	Organization Membership Dates (mm/dd/yy): From To
Are you a Resident of Orange County?	Yes No If "Yes", continuous resident since what year? If "No", please state your County
Previous Board Membership	Have you ever served on an Orange County Board? Yes No If "Yes", please state name of board and date served. Year Served
By submitting this form for consideration, I acknowledge the following: I understand the responsibilities associated with being a Board member, and I have adequate time to serve on the Board.

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