Application-Diaz, Michael PBOT 12/20/12 CITY OF ATLANTIC BEACH
BOARD / COMMITTEE MEMBER APPLICATION FORM
Please check the box beside each Board or Cotinat 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 availabblen .,•;e2:012f this form.)
Code Enforcement Board Community Development Board
Pension Board of Trustees a City Clerk Board Member Review Committee
Cultural Arts and Recreation Advisory Committee
DATE: / APPLICANT'S NAME: Af
l le: /it:1"-P
ADDRESS: #8,0 S%4 „6,L„ .7.417/4ai
DAYTIME PHONE: ( q..)01.117—/K23 EVENING PHONE: ( Y>
E-MAIL ADDRESS: in t k'dt —45 FAX:
Please explain any employment experience, board/committee experience, and/or community volunteer experience
relative to the board/commit ee ap lyi for '_ /� /
Div` c G c., f� •�l
AS
45/e/s F1-1‘ a) Pk Fri-‘Jk"" PilLe
1' i c'e✓s'c c,-( Fz/ie 30 Q.K4 t hit
velv As frx ,4‹,ega.e /, ea,c
Att"-ed of DfierAilt- G€7- IILJ{I 61-44tes) 04,41 lusts
nvdl✓ I4 (k.e I ' slat, I S . t Al€ n kit-4 h6A-YJ d�
lva /141:14.4-C -, ..../ '- .4)/7 8.4rflif Pbsec ' azr/4-170K g ' . ,/
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.
.1-1144k • eds i fz rens 6 o `Q A-a
1,-)45 D'Lc.Q jw A-)o✓' C %,a S toe G Gc-t
1 cs- (5/A. C 9�e•e S v vti.. !tit ion
-/i4-� 9�Qi� aL,d `o v tot A:3 S 410
^
147 114/611a zut CgZ-30
P e 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.
1