Form must be filled out completely

Name

Date

Home Address

Zip Code

Home phone

Cell Phone

Email

Number of years as city resident

Owner or Renter

District #

Occupation

Business Name

Business Address

Work Phone

Fax

Education (highest degree / level)

Are you registered to vote in Broward County

Yes

No

Identify the board / committee(s) to which you request appointment (Please rank in order of preference)

(1)

(2)

(3)

(4)

Are you interested in serving on more than one board / committee?

Yes

No

If so, how many?

Please describe your professional and/or volunteer experience or background, which best qualifies you for selection to the board / committee

If you are applying for a board / committee, which has specific requirements / categories, please detail how your background and/or experience meets the required criteria.

Applicant must attend at least one board/committee meeting prior to consideration of application for every board applied. Please list board/committee meeting you attended in the last year.

Have you ever served on a city advisory board in the past?

Yes

No

If yes, please describe

Are you presently employed by the City of Hollywood?

Yes

No

If so, in what capacity?