Application- Saggau, Tim CEB, PBOT, CARAC & CDB CITY OF ATLANTIC BEACH Received
BOARD/COMMITTEE MEMBER APPLICATION FORM
JAN 1 4 22013
Please check ('I) the box beside each Board or Committee that you are applying to serve on. you check more than
one , please rank your interest in each board / committee by order of priority.
(A` summary of each board/committee is available on page 2 of this form. ) Office of City Clerk
v Code Enforcement Board [./Community Development Board
Pension Board of Trustees Board Member Review Committee
Cultural Arts and Recreation Advisory Committee
DATE : JI ` 30 -- 12. APPLICANT ' S NAME : urn 514 6641-.
ADDRESS : 02032. OuwA VI5 # CGS , A */ANPic dead. Ft .
DAYTIME PHONE : 50 'i - $ 3 $ - 390 o EVENING PHONE : 9a c - fl $ 3 5' oO
E- MAIL ADDRESS : Tim 90.'55 Ac J p'-Loc . FAX :
corn
Please explain any employment experience, board/committee experience, and/or community volunteer experience
relative to the board/committee applying for.
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Please provide a brief explanation of your interest or any special qualifications you have in this field and your reasons
for wishing to be appointed to this board/committee . / n ,[ ,(�
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Please return completed form to
Donna L. Bartle, City Clerk, 800 Seminole Road, Atlantic Beach, FL 32233
PLEASE NOTE : Members of the Code Enforcement Board, Community Development Board and Pension Board of
Trustees are required to file Statement of Financial Interest Forms . Also, information regarding "Conflict of Interest"
is provided on page two of this application. This application will expire two (2) years after date of submittal . •
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