Application- Lada, Jennifer PBOT 9-3-15 %-1 l r yr ti i Ltiiv 1 it.. nr.ti� n
BOARD / COMMITTEE MEMBER APPLICATION FORMceived
Please check (A) the box beside each Board or Committee that you are applying to serve ons`IP you chic 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
Code Enforcement Board Community Development Board
Pension Board of Trustees Board Member Review Committee
Cultural Arts and Recreation Advisory Committee
DATE: g31' klj APPLICANT'S NAME: 3.e.n 6-ki Lczjh
ADDRESS: 1Da•-1 OC CCY\ `D I V d '(U-4,61fc, ade) - 3 33
DAYTIME PHONE: ( oLf) 'l0 f'4 I EVENING PHONE: 4.5a
E-MAIL ADDRESS: LL—Pr 91A \- FAX: (
Please explain any employment experience, board/committee experience, and/or community volunteer experience
relative to the board/committee applying for.
l'atisitruf ft ,,( 361in Snybssn, Campaloll. s fr•(.a 5+) 14-Nr (0,-P
rafiff o4- er 1
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.
, . ALP.tl mull, well �. l t1 44.I /it . /.• �i a! 1 A IEI JA!
..11 I. .TV . llJ. /.R RZMILYW ice!AL/.
- (
1 /�
fliffereinn I
1L/J
us. 1 . .• L. - •: .th. ! S ' I ! PAI
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.