2. Application for Appointment to City Board or Committee
4. First Name*
5. Last Name*
7. Board/Committee*
   -- Select One --Airport AuthorityBoard of Adjustments and AppealsCensus Redistricting CommitteeCitizens and Police Community Relations Advisory BoardCode Enforcement BoardGeneral Employees Pension BoardHistoric District Regulatory BoardHousing AuthorityLake Wales Firefighter Pension BoardLake Wales Police Officers Pension BoardLibrary BoardPlanning and Zoning BoardRecreation Advisory CommissionTree Advisory Board

   Please Select Board or Committee you are applying for.

8. Applying For:*

   1. Reappointment
   2. New Appointment
10. City Resident?*

    1. Yes, Full-time
    2. Yes, Part-time
    3. No
11. City Business Tax?

    1. Yes
    2. No
12. Registered Voter?*

    1. Yes, Florida
    2. Yes, Other
    3. No
13. Own Property in City?

    1. Yes
    2. No
15. Email Address
16. Home/Mobile Number*
    Enter the best phone number to contact you.
18. Home Address*
20. City*
21. State*
22. Zip*
24. Business Address
26. City
27. State
28. Zip
29. Business Phone Number
    Enter your business phone number
31. Working Status

    1. Employed
    2. Retired
33. Employer
34. Occupation/Type of Business
36. If Applicant is not a City resident or does not pay business tax to the City, please provide physical address of property owned within the city limits:
38. Special knowledge or experience applicable to function of board/committee:*
40. Other Community Involvement:
42. Why do you want to serve on this board?*
44. Fla. Statute 760.80 requires the City of Lake Wales to maintain and report the following information:
46. Race/Ethnicity*

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

    1. Male
    2. Female
48. Physically Disabled*

    1. Yes
    2. No
50. I understand that I may be required to complete a Financial Disclosure Form in accordance with the requirements of Florida Law for every year during which I serve as an appointee. I further understand that refusal to file a required Financial Disclosure will result in my removal from the board/commission/committee to which I have been appointed.*
    Applicant Initials
52. Have you ever been convicted of a felony?*

    1. Yes
    2. No
54. If yes, please explain in the box provided.
56. List 3 references who reside in the city:
58. First Name
59. Last Name
60. Phone Number
    Enter phone number
62. First Name
63. Last Name
64. Phone Number
    Enter phone number
66. First Name
67. Last Name
68. Phone Number
    Enter phone number
70. Contact City Clerk's Office to schedule appointment with board chairman and board support staff.
72. Applicant Signature*
    Please type your name in the box provided
73. Date*
    Date
    Please enter date
75. If the applicant is not appointed at the next City Commission meeting scheduled for the purpose of making appointments, this application will be retained on file for 6 months.
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field