Emerald Hills Safety Enhancement District Board Interest Form

2. First Name*

3. Last Name*

4. District # You Live In.*

6. Home Address*

7. City*

8. State*

9. Zip Code*

11. Home Phone

12. Cell Phone

13. Email Address*

15. Owner or Renter *

16. Number of years as city resident*

17. Are you registered to vote in Broward County?*
    -- Select One --YesNo

18. Education (highest degree / level)

20. Occupation*

21. Work Phone

23. Business Name*

25. Business Address

26. City

27. State

28. Zip Code

32. How many elections have you voted in and when was the last time you voted?*

34. How many City Commission or board meetings have you attended in the last 2 years? Please list:*

36. Why do you wish to serve as a member of the Emerald Hills Safety Enhancement District Board?*

38. If appointed, what specific contribution(s) will you bring to the Emerald Hills Safety Enhancement District Board?*

40. Please describe your qualifications as an applicant including your professional and/or volunteer experience or background.*

44. Do you currently serve on any City or County boards or committees? Please list.*

46. Have you ever served on any City or County advisory boards? Please list.*

48. List community / civic service involvement.*

50. I acknowledge that if appointed to serve, I will be required to file the Statement of Financial Interest Disclosure Form 1, as required by Florida Statute 112.314(1)(a).*

52. Attach Resume (only .doc and .pdf files)*

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53. 1. Receive an email copy of this form.
54. Email address

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55. Submit

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