CITIZEN PARTICIPATION APPLICATION

I wish to apply for appointment to the .
I understand that if appointed, I will serve in a voluntary capacity on this advisory board.

Name: Phone:
Address: Fax:
  Email:
Occupation: Phone:
Address: Fax:

Are you a registered voter? Yes No In what district do you reside?

How long have you lived in Putnam County?

Professional Qualifications:

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What would you hope to accomplish by your participation?

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When are you NOT available for meetings?

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By my entering my typed signature below, I certify that the information on this application
is true and complete. I understand that false statements will be cause for denial of
appointment. I also understand that, if appointed, the State of Florida my require me to
file a financial disclosure with the Putnam County Supervisor of Elections within thirty (30)
days of my appointment, and each year thereafter, covering my term of appointment.


November 20, 2017
TYPED SIGNATURE DATE