CITIZEN PARTICIPATION APPLICATION
 

I wish to apply for appointment to the                                                                                            , I understand that if
appointed, I will serve in a volunteer 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:
  
                                                                                                                                                                                        
                                                                                                                                                                                        
                                                                                                                                                                                        
                                                                                                                                                                                        
 
What would you hope to accomplish by your participation?
 
                                                                                                                                                                                        
                                                                                                                                                                                        
                                                                                                                                                                                        
                                                                                                                                                                                        
 
When are you NOT available for meetings?
 
                                                                                                                                                                                        
                                                                                                                                                                                        
                                                                                                                                                                                        
                                                                                                                                                                                        
 
By my 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
may 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.
   
   
  
  
                                                                                                                                                                                        
SIGNATURE OF APPLICANT                                                                                                     DATE