Simon, Rita A. tcb & carac 1-14-09
CITY OF ATLANTIC BEACH BOARS COMMITTEE MEMBER APPLICATION FOR Please check the box beside each Board or Committee that you are applying to serve on I qu e ore than one please rank your
interest in each board committee by order ofpriority n Asummary ofeach cboommaitrtedeis available on page 2 ofthis form OflfwofCity Cledc Code Enforcement Board Community Development
Board Pension Board of Trustees Tree Conservation Board Cultural Arts and Recreation Advisory Committee Board Member Review Committee DATE b ASPPLICANT NAME l D ADDRESS c DAYTIME PHONE
Q EVENING PHONE a G7 OS EMAIL ADDRESS QCpS fVCO JQ L FAX Please return completed form to Donna L Bussey City Clerk 800 Seminole Road Atlantic Beach FL 32233 PLEASE NOTE This application
will expire two2years after date ofsubmittal 1 Please explain any employment experience boardlcommittee experience aonrd community volunteer experience relative to the cboommaitrtedeapplying
for Please provide a briefexplanation of your interest or any special qualifications you have in this field and your reasons for wishing tobe appointed to this cboommaitrtede