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1. Application Date: (Required.)

Date

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2. Applicant Name: (Required.)

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3. Address: (Required.)

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4. County Commission District in which you reside: (Required.)

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5. Daytime Phone: (Required.)

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7. Occupation: (Required.)

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8. Current Employer (if applicable):

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9. Are you currently serving as an Elected Official? (Required.)

Service on the Charter Review Commission may implicate the dual officeholding prohibition in Art. II, sec. 5(a), Florida Constitution for applicants who already hold, or are seeking, an office subject to this section.

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10. Are you affiliated with, or do you represent, a current or prospective County vendor? (Required.)

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11. Are you an officer, director, or employee of an organization that receives County funding? (Required.)

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12. Please describe your employment, board/committee, and/or other community involvement that you believe is relevant to service as a Charter Review Commissioner. (Required.)

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13. Please briefly explain your interest in serving on the Charter Review Commission. (Required.)

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14. Have you ever previously served on the County’s Charter Review Commission or a charter review commission/committee? (Required.)

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15. Please describe any goals or changes you may wish to see addressed in or made to the Broward County Charter. (Required.)

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16. By entering your full name below, you certify that all facts provided in this application are true to the best of your knowledge and belief. (Required.)

“CONFLICT OF INTEREST” NOTICE:

Members of Broward County’s Charter Review Commission are public officers subject to various provisions within Part III of Chapter 112, Fla.Statutes, the Code of Ethics for Public Officers and Employees. This Code defines “conflict” or “conflict of interest” to mean a situation in which regard for a private interest tends to lead to disregard of a public duty or interest. Fla.Stat. §112.312(8). If you can foresee a potential “conflict” or “conflict of interest” should you be appointed to the Charter Review Commission, you are strongly encouraged to disclose that potential conflict as soon as possible in the appointment process.

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