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Pertinent education or relevant technical skill:

Employment history (Please include last 3 employers, position and years served):

Present or prior service in governmental boards and committees

Describe your professional and/or volunteer experience or background that would best qualify you for an appointment to the Board/Committee/Commission you have selected:

If you are applying for a Board/Committee/Commission that has specific requirements, please detail how your background and/or experience meets the required criteria:

If not selected for the Board/Committee/Commission indicated above, please list any additional Boards/Committees/Commissions for which you would like your application submitted. (Please rank in order of preference):

If appointed to serve, a Financial Disclosure Form is required, upon appointment, annually and upon resignation/retirement. If proof of residency is required by your Board/Committee/Commission, please provide a utility bill and/or a lease. If proof of ownership/interest in a business in North Miami is required, please provide a current certificate of use and/or a business tax receipt

Have you ever been convicted of a felony?*

Yes

No

Do you currently have a violation(s) of North Miami codes?*

Yes

No

If yes to either one of the questions above, please explain in detail:

I hereby attest to the accuracy and truthfulness of the application. I certify under oath, and penalty of perjury, that all information shown above is true and correct. I do understand that any appointment to a Board/Committee/Commission obtained on a misrepresentation of a material fact shall be null and void.

Electronic Signature Agreement

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

I agree.

Date:*

Date:

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City of North Miami Board & Commission Application

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