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2. City of Cocoa Application for Board/Committee Membership
   City Code requires prospective and existing board members to fill out an application, consent to a standard criminal background check*, be duly registered to vote in Brevard County, and be a resident or an owner of real property in the City of Cocoa. City Code also prohibits a person from serving on a City Board or Committee if that person has been convicted of a felony, unless their civil rights have been restored.
4. (Please Print)
6. First Name*
7. Last Name*
8. Application Date*
   Application Date
10. Address1*
12. City*
13. State*
14. Zip*
16. Cocoa City Council District*
    -- Select One --District 1District 2District 3District 4

    Please select the district that you live in. This information can be found on your Voter's Registration card.

18. Home Phone Number*
19. Work Phone Number
20. Cell Phone Number
21. Other Phone Number
23. Place of Business
25. Title/Position Held
27. Date of Birth**
    Date of Birth*
28. E-mail Address
30. *The information being requested is necessary in order to conduct a background check. Information will be used for those purposes only.
34. Various City Boards/Committees Available*

    (Please Check All Those That Interest You)

    1. Affordable Housing Advisory Committee
    2. Board of Adjustment
    3. Code Enforcement/Drug Related Public Nuisance Board
    4. Housing Authority
    5. Pension Board - Fire
    6. Pension Board - General Employees
    7. Pension Board - Police

    1. Planning & Zoning Board
    2. Police Community Relations Advisory Board
    3. Redevelopment Agency (Cocoa)
    4. Redevelopment Agency (Diamond Square)
    5. Utilities Advisory Board
    6. Sustainability Advisory Board
38. Eligibility
40. Have you been a City of Cocoa resident for at least 6 months?*

    1. Yes
    2. No
42. Do you own property or a business in Cocoa?*

    1. Yes
    2. No

44. If yes, please list all addresses you own in the City of Cocoa:

46. Address1
48. Address2
50. City
51. State
52. Zip
54. Address1
56. Address2
58. City
59. State
60. Zip
62. Are you registered to vote in Brevard County, Florida?*

    1. Yes
    2. No
64. Have you ever been convicted or found guilty, regardless of adjudication, of a felony in any jurisdiction? Any plea of no contest shall be considered a conviction for purposes of this question.*

    1. Yes
    2. No
65. If yes, have your civil rights been restored?

    1. Yes
    2. No
67. Do you consent to a standard criminal background check?*

    1. Yes
    2. No
71. Miscellaneous Information
73. Do you currently serve on any other City of Cocoa board?*

    1. Yes
    2. No
75. Are you related to a City of Cocoa Councilmember by blood, adoption, or marriage?*

    1. Yes
    2. No
77. Potential Conflict of Interest: Have you ever been engaged in the management of any business enterprise that has a financial interest with the City of Cocoa? Please provide details, such as the name of the enterprise, the nature of the business, and the positions you hold or have held.*

    1. Yes
    2. No
79. If yes, please provide details.
83. Interests and Experience
85. Additional Information May be Attached
87. Briefly state your interest in serving on a City board or committee. Please include information relating to prior service on any governmental board or committee, and any specialized skills or training you feel will help you to qualify for membership on the desired City board or committee. *
91. State Reporting Requirements
    Section 760.80, Florida Statutes, requires that the City annually submit a report to the Secretary of State disclosing race, gender, and physical disabilities of board and committee members. Please check the appropriate boxes:
93. Race*

    1. African-American
    2. Asian-American
    3. Hispanic-American
    4. Native American
    5. Caucasian
94. Gender*

    1. Male
    2. Female
95. Disability

    1. Physically Disabled
100. Applicant Certification
     By filling this application with the City of Cocoa, I do hereby acknowledge the following: 1. This application, when completed and filed with the Office of the City Clerk, is a public record under Chapter 119, Florida Statutes, and is open to public inspection. 2. I am responsible for keeping the information on this form current and provide any changes or updates to the Office of the City Clerk. 3. I consent to filing a Statement of Financial Interests (Form 1) required if required for the board in which I am appointed to. 4. If appointed to a board/committee, I acknowledge that this is my obligation and duty to comply with the following: Code of Ethics for Public Offices (Florida Statutes, Chapter 112, Part III) Florida Sunshine Law (Florida Statutes, Chapter 286) http://www.flsenate.gov/Statutes.
102. Signature*
     By typing in my full name above, I am acknowledging that the above information is accurate and I understand all of the information provided to me on this application and that I consent to all of the above.
103. Date:*
     Date:
105. City Board and Committee Information as well as Meeting Information
     Boards and Committees
107. All meetings are subject to change in dates and/or may be canceled with the approval of the City Manager (with the exception of the regular Council meetings), dependent upon whether there are items or cases to be considered. Other meetings of boards not listed above are held on an infrequent basis to which there is no standard or specified monthly date. (Please refer to the preceding "Description of Boards and Committees".) The three pension boards generally meet quarterly, and meetings may be held more often, depending on necessity. The Drug Related Public Nuisance Board holds meetings coinciding with the Code Enforcement Board; however, it meets infrequently on an as needed basis. THIS INFORMATION IS PUBLISHED BY THE CITY CLERK'S OFFICE IN AN EFFORT TO BETTER INFORM CITIZENS ABOUT THEIR CITY GOVERNMENT.
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109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit Submit and Print

* indicates a required field