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2. Select the Board/Committee which you are applying for *
   -- Select One --Historic Environmental Preservation BoardPlanning and Zoning Appeals BoardCivil Service BoardCommunity Relations, Recreations & Activities Advisory BoardHousing Authority & Nuisance Abatement BoardCanvasing Board*Charter Review Board

   *AD HOC - board will be formed when necessary to deal with a specific issue

4. First Name*
5. Last Name*
7. Home Address*
   Proof of residency required
9. City*
10. State*
11. Zip*
13. Email Address*
14. Home Phone Number*
16. Mailing Address
18. Cell Phone Number*
19. Business Phone Number
21. Length of Residency in Opa-locka*
23. Employer*
24. Occupation*
26. Professional Activities
28. Volunteer Activities
30. Why do you wish to serve on this board/comittee?
32. What areas of concern would you like to see addressed by this board/committee?
34. Qualifications for serving
36. Other municipal or county boards/committees or non-profits on which you are serving
38. List three local personal references and phone numbers (References must be non-related and non-city employees)
40. Name
41. Phone Number
43. Name
44. Phone Number
46. Name
47. Phone Number
49. Application is effective for one year from date of completion. If you have any questions, please call the City Clerk's Office at 305.953.2800/2801
51. Conflict of Interest

    If a board member believes he/she has a conflict or potential conflict of interest on a particular issue, that member should state these beliefs to the other member of his/her respective board during a public meeting. The member should state the nature of the conflict, detailing that he/she has a separate, private or monetary interest, either direct or indirect, in the issue under consideration. The member should then excuse himself/herself from voting on the matter. Florida Sunshine Law applies to all city boards. Financial Disclosure form is required, if appointed to serve.

53. I, the applicant for this board application, warrant the truthfulness of the information provided in this application.
54. Electronic Signature*
56. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the Terms of Acceptance.*
57. Response*

    1. Agree
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59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit Submit and Print

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