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Application- Hansen, Kirk CDB 10-13-17 I CITY OF ATLANTIC BEACH 3// BOARD/ COMMITTEE MEMBER APPLICATION FORM Please check(1) 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 su ary of each board/committee is available on page 2 of this form.) Code Enforcement Board V Community Development Board 111 Pension Board of Trustees Board Member Review Committee ■ Cultural Arts and Recreation Advisory Committee DATE: ) / cJ/5APPLICANTS NAME: k/' j2' i 4/ V 5nJ ADDRESS: 23 q3 0064,J A'6/ Cr; A'/ DAYTIME PHONE: ?/O - 476.“) EVENING PHONE: � " Ce7 E-MAIL ADDRESS: SCNM IZ c 6 Ire FAX: Please explain any employment experience, board/committee experience, and/or community volunteer experience relative to the board/committee applying for. o,J ct9ITIAluto c'Lo #441C 4) /3GA24 fib if 7N' / sr S ref's 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. /412. 'lc $O /N i.gcC, " A)6 CO,e1'c,? or ,9-71it LID C 4c AQ1 w/1� -( t/L). c/re)/Q6 (,/TJZr/t) S ( 64-77:-D i " e V • A7t) eeu /iA4C.r 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. 1