Application- Keith, Louis CEB 8-17-12 CITY OF ATLANTIC BEACH Received
BOARD / COMMITTEE MEMBER APPLICATION FORM
AUG 1 7 2012
Please check ( V) the box beside each Board or Committee that 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 available on page 2 of this fonii .) Office of City Clerk
Code Enforcement Board Community Development Board
Pension Board of Trustees Board Member Review Committee
Cultural Arts and Recreation Advisory Committee
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DATE: 65)/// -3/42 APPLICANT ' S NAME : C-' ez, ..f Xi" ta
ADDRESS : /d 'LC 2e) pa ''locch j7 1. &. 7v23
DAYTIME PHONE : jG- /. q 3 - 6 .37 EVENING PHONE : ore22-
E-MAIL ADDRES Sh Y kre 4 /4 4 AX:
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.
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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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