Member Appointment Questionnaire

Question Title

* 1. Name:

Question Title

* 2. 2. Seat of Interest

Arnold Palmer Hospital for Children in Orlando

Florida Hospital for Children in Orlando

Joe DiMaggio Children's Hospital in Hollywood

Johns Hopkins All Children's Hospital in St. Petersburg

Nemours Children's Hospital in Orlando

Nicklaus Children's Hospital in Miami

St. Joseph's Children's Hospital in Tampa

University of Florida Health Shands Hospital in Gainesville

University of Miami Holtz Children's Hospital of Miami

Wolfson Children's Hospital in Jacksonville

At-Large Representative-
Primary Hospital Affiliation:

Question Title

* 3. Specialty

Board Certified Cardiologist (adult)

Board Certified Pediatric Cardiologist

Pediatric Cardiologist

Pediatric Cardiovascular Surgeon

Question Title

* 4. Contact Information

Email:

Secondary Email (or Assistant/Secretary):

Telephone Number:

Secondary Telephone Number:

Mailing Address:

City, Zip Code:

County of Residence

Question Title

* 5. Have you ever been arrested, charged, or indicted for a violation of any federal, state, county, or municipal law, regulation, or ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less was paid.)

Yes

If yes, please give details (Date, Place, Nature and Disposition):

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* 6. State your experience and interest or elements of your personal history that qualify you for this appointment:

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* 7. Please list all degrees, professional certifications, or designations related to the subject matter of this appointment:

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* 8. Have you received any awards or recognitions relating to the subject matter of this appointment?

Yes

If yes, please list:

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* 9. Identify all association memberships and association offices held by you that relate to this appointment:

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* 10. Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or had other direct dealings during the last four years with any state or local governmental agency in Florida, including the office or agency to which you are seeking appointment?

Yes

If yes, please list name of business, your relationship to business and the business relationship to the Agency:

Question Title

* 11. Have members of your immediate family (spouse, child, parents(s), siblings(s)), or businesses of which members of your immediate family have been owners, officers, or employees, held any contractual or other direct dealings during the last four years with any state or local governmental agency in Florida, including the agency to which you are seeking appointment?

Yes

Other (please specify)

Question Title

* 12. MEMORANDUM

AS A GENERAL MATTER, APPLICATIONS FOR ALL POSITIONS WITHIN STATE GOVERNMENT ARE PUBLIC RECORDS, WHICH MAY BE VIEWED BY ANYONE UPON REQUEST. HOWEVER, THERE ARE SOME EXEMPTIONS FROM THE PUBLIC RECORDS LAW FOR IDENTIFYING INFORMATION RELATING TO PAST AND PRESENT LAW ENFORCEMENT OFFICERS AND THEIR FAMILIES, VICTIMS OF CERTAIN CRIMES, ETC.

IF YOU NEED ADDITIONAL GUIDANCE AS TO THE APPLICABILITY OF ANY PUBLIC RECORDS LAW EXEMPTION TO YOUR SITUATION, PLEASE CONTACT THE OFFICE OF THE ATTORNEY GENERAL.

The Office of the Attorney General
PL-01, The Capitol
Tallahassee, FL 32399
(850) 245-0158

IF YOU BELIEVE AN EXEMPTION FROM THE PUBLIC RECORDS LAW APPLIES TO YOUR SUBMISSION, PLEASE CHECK THIS BOX:

Yes

If Yes: I assert that identifying information provided in this application should be excluded from inspection under Public Records Law. Please indicate what section of Florida Statutes provides this in your particular situation: