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Advisory Board
Application for Appointment

This is a secure server. All information you submit will be transmitted in a secure fashion.
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

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

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.