At-Large Board Member Application 2021

Personal Information

* Indicates required field.

Question Title

* 1. Name

First

Middle

Last

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* 2. Contact Information

Address Line 1

Address Line 2

City

State

County

Zip Code

Home Phone Number

Mobile Number

eMail Address

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* 3. How may we best contact you? (Check all that apply)

eMail

Work Phone

Home Phone

Mobile Phone

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* 4. Have you been residing within Miami-Dade County during the past twenty-four (24) months?

Yes

No