City of Deltona, FL - Citizen Board/Committee Application

Choose from the following:

Checkboxes	Checkbox Description	Checkboxes	Checkbox Description
	Affordable Housing Advisory Committee		Firefighter's Pension Plan Board of Trustees
	Economic Development Advisory Board		Planning & Zoning Board
	Parks & Recreation Advisory Committee		Special Magistrate
	Parks & Recreation Senior Advisory Sub-Committee		William S. Harvey Scholarship Selection Committee
	Parks & Recreation Citizen Accessibility Advisory Sub-Committee		Other Boards/Committees (Write Board Name in "Additional Information")
	Parks & Recreation Youth Advisory Sub-Committee

Please provide the following information:

Field Description	Field Data	Required Field
Name:		required
Email:		required
Address:
City:
State:
Zip:
Phone:
Alt Phone:
Fax:
Organization:

Number of Years as a Deltona Resident

Field Data

What Commission district do you reside in?

Field Data

Are you a registered voter in Volusia County?

Field Data
Yes No Not Applicable/Youth Boards

Who is your employer? (Please include number of years, address, phone number and title/position)

Please summarize your work experience.

List any volunteer service organizations, clubs, or professional societies you are a member of and give the positions or titles you have held.

Have you ever served on a committee or advisory board? If so, give the details, including any positions held. Have you ever held public office? If so, give the details, including offices involved, whether elected or appointed, and the length of service.

Describe any additional knowledge, skill, education, or experience you have, which would assist you in the duties of this Board/Committee.

Explain why you want to serve on this Board/Committee, and include any potential contribution you selection would bring.

Potential conflict of interest: Do you do business, or are you engaged in the management of any business enterprise that has a financial interest with the City of Deltona? Please give details, including the name of the enterprise, the nature of the business, and the position you hold.

Have you ever been convicted for violation of any federal, state, county, or municipal law, regulation, or ordinance? If so, give details. Do not include traffic violations or fines of $100 or less that were imposed, unless it also included a jail sentence.

List names, addresses, and telephone numbers of at least three persons who are in a position to comment on your qualifications and of whom inquiry may be made by the City of Deltona.

Additional Information or Comments

I declare the foregoing facts to be true, correct, and complete.

I do not agree
I agree