Application- Blocker, Judy - CARAC 7-13-18 Withdrew on 9-6-19CITY OF ATLANTIC BEACH
BOARD / COMMITTEE MEMBER APPLICATION FORM
-Ise check (1) the box beside each Board or Committee that you are applying to serve on. If you check more than
, 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.)
Code Enforcement Board
Pension Board of Trustees
Cultural Arts and Recreation Advisory Committee
Community Development Board
Board Member Review Committee
LA_ �urfn\ )r-iSr-Ree_rein►t,_.
A�� iso rte Co wo•AA' I�..
DATE: F - i 3 - /' APPLICANT'S NAME: 3 c Vj ilet., C-1
ADDRESS: /Of (A if.
DAYTIME PHONE: 1/( 4/0 / 2- EVENIM PHONE:(eJ y 53/2_,
E-MAIL ADDRESS: ► )o ,,Ac :A./ e 14 FAX: -`-'
Please explain any employment experience, board/committee experience, and/or community volunteer experience
relative to the board/committee applying for.
914.4,t)
ejlud.�ar�' er/vZ2P �S.441 42x1,
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.
t;1_, `1 %U -e di -1a,', LA&ll-, ,Gi.� zi, _dam-_ Pt_ !e_
/ i . aI_ ./ ./',.' I'„ / _ / /'. 1,__
Ag, Aizet/Li 44441,-J— _, ,p,4:-: ,11„2,1 & p_ iz.",_,
, , li- , , ...A _, alb
d•--4.6.-e__ (-4Afoia .40,4_, -->dial- ' ,,,i,e_dp&lai"..,;-;-2.4,, t/
r./ifit ' - ��� t� ,0211,aep.1-6,-,-0-4 12-21..-d6u
0 10 41-/ -17{-e- .41.4' Q Q e..
Please return completed form to
Donna L. Bartle, City Clerk, 800 Seminole Road, Atlantic Beach, FL 32233
ASE 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.