Application- Kaplan, Marina CARAC, CDB & BMRC 3-9-16 CITY OF ATLANTIC BEACH
BOARD / COMMITTEE MEMBER APPLICATION FORM Received
Please check ("I) the box beside each Board or Committee that you are applying to serve on . IftM chegk ) ( 0‘ e 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
Code Enforcement Board 2 Community Development Board
Pension Board of Trustees Board Member Review Committee
I Cultural Arts and Recreation Advisory Committee
DATE : - i ILa APPLICANT ' S NAME : M ariha I pIan
ADDRESS : LO IQ, C - h` _k at F L 322 33
DAYTIME PHONE : 3o2 - W2, -- 1 ) 3S EVENING PHONE : 39 2 - 89 ? - '9135
E- MAIL ADDRESS : pakm r IL.ktOI n (DO FAX : ,& IA =
Please explain any employment experience , board/committee experience, and/or community volunteer experience
relative to the board/committee applying for . f
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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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