Application-Diaz, Michael PBOT 12_20_12 CITY OF ATLANTIC BEACH
BOARD / COMMITTEE MEMBER APPLICATION FORM
Please check ('J) the box beside each Board or Collgifinetihat you are applying to serve on. If you check more than
one, please rank your interest in each board / committee by order of priority.
(A summary of each board/committee is availabenv . ,•,; e2:012f this form.)
Code Enforcement Board Community Development Board
Pension Board of Trustees Otte acity Cie* Board Member Review Committee
Cultural Arts and Recreation Advisory Committee
DATE : / APPLICANT ' S NAME : A? ' e l
ADDRESS : N9,0 9O c& /A - �� a'i /ce„ 15,z „ r C 6 ' I( j U
DAYTIME PHONE (ra7 7-/K23 EVENING PHONE: ( die 7�/8 73
E-MAIL ADDRESS : in / kil 4- — 45 @) FAX:
Please explain any employment experience, board/committee experience, and/or community volunteer experience
relative to the board/commit ee ap lyi for Ac Lt 2 /
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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.
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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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