Application-Simon, Rita A. TCB & CARAC 1-14-09CITY OF ATLANTIC BEACH
BOARS /COMMITTEE MEMBER APPLICATION FOR~~
Please check (~) the box beside each Board or Committee that you are applying to serve on. I ~qu e ore than
one, please rank your interest in each board /committee by order of priority. ~~n ~~
(A summary of each board/committee is available on page 2 of this form.)
Oflfw of City Cledc
^ Code. Enforcement Board ^ Community Development Board
^ Pension Board of Trustees ~ Tree Conservation Board
~'" Cultural Arts and Recreation Advisory Committee ^ Board Member Review Committee
DATE: ~ b APPLICANT'S NAME: ~ l- ~ ~ ~ ~, '~ D ~
ADDRESS: ~.,, ` ~~, c.~
DAYTIME PHONE:~_~ ~" ~ Q ~ ~ EVENING PHONE: a ~. G'7 - ~ O S~
E-MAIL ADDRESS: Q ~-CpS~ ( f VCO J~ Q L. • FAX: ~ ~~
Please return completed form to
Donna L. Bussey, City Clerk, 800 Seminole Road, Atlantic Beach, FL 32233
PLEASE NOTE: This application will expire two (2) years after date of submittal.
1
Please explain any employment experience, boardlcommittee experience, and/or community volunteer experience
relative to the board/committee applying for.
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.