TOWN OF LADY LAKE BOARDS/COMMITTEES APPLICATION

DATE: ____________________

NAME:_________________________________________________________________

MAILING ADDRESS: ____________________________________________________

LOCATION OF RESIDENCE: _____________________________________________

DO YOU RESIDE WITHIN THE TOWN LIMITS OF LADY LAKE: ______________

IF NOT DO YOU RESIDE IN LAKE COUNTY:___________

HOME PHONE: __________________  WORK PHONE:________________________

WILLING TO SERVE ON THE FOLLOWING BOARDS OR COMMITTEES:

_______________________________________________________________________

_______________________________________________________________________

NATIONALITY (optional)_________________________________________________

This information is for use in the Annual Florida Department of State Report only.

OCCUPATION: _________________________________________________________

BUSINESS ADDRESS: ___________________________________________________

PHONE: ________________________POSITION: _____________________________

TRAINING OR EXPERIENCE RELATED TO ACTIVITIES OF BOARDS OR

COMMITTEES TO WHICH APPOINTMENT IS SOUGHT:

_______________________________________________________________________

_______________________________________________________________________

MEMBER OF THE FOLLOWING PROFESSIONAL ORGANIZATIONS:

_______________________________________________________________________

HAVE YOU SERVED ON A TOWN BOARD/COMMITTEE IN THE PAST? _______

IF YOU ANSWERED YES- DATES: ________________________________________

NAME OF COMMITTEES/BOARDS: _______________________________________
 

 LIST THREE REFERENCES THAT THE TOWN MAY CONTACT- NAME, ADDRESS, AND PHONE NUMBER:

1.                  _____________________________________________________________________

2.                  _____________________________________________________________________

3.                  _____________________________________________________________________

ADDITIONAL INFORMATION MAY BE ATTACHED TO THIS FORM.

I WILL ATTEND MEETINGS IN ACCORDANCE WITH THE ADOPTED POLICIES OF THE TOWN.  IF AT ANY TIME MY BUSINESS OR PROFESSIONAL INTERESTS CONFLICT WITH THE INTERESTS OF THIS BOARD OR COMMITTEE, I WILL NOT PARTICIPATE IN SUCH DELIBERATIONS OF THE BOARD OR COMMITTEE. 

__________________________

SIGNATURE OF APPLICANT

PLEASE RETURN APPLICATION TO:

TOWN OF LADY LAKE

409 FENNELL BLVD

LADY LAKE, FL.  32159

PLEASE NOTE:  YOU MAY BE REQUIRED TO FILL OUT A FINANCIAL DISCLOSURE FORM.