i/ EXECUTIVE OFFICE OF THE GOVERNOR, THE CAPITOL
GUBERNATORIAL APPOINTMENTS ONLY
Please complete each blank on all five pages of the questionnaire and return it to the Goveror's Office, Appointments Director, The
Capitol, Tallahassee, Florida 32399-0001. The information from this page of the questionnaire will be used exclusively by the
GOVERNOR'S OFFICE. Please type or use black ink.
1. Board of Interest:
2. Occupation (exact title):
3. Do you have any handicapping or disabling conditions? Yes 0 No 0 If "Yes", please explain.
* 4. Sex Male 0 Female D
"* 5. Race White, non-Hispanic (W) 0 American Indian/Alaskan Native (A) 0
Hispanic (H) 0 Asian/Pacific Islander (P) O
Black (B) O
6. Are you willing to file financial disclosure statements while serving in an appointed position? Yes 0 No 0
NOTE: Filing financial disclosure statements generally includes reporting: (1) all sources of income exceeding five percent (5%)
of your gross salary; (2) income to a business entity exceeding ten percent (10%) of its total income and ten percent (10%) of your
income; (3) location and description of real property; (4) all persons who gave you gifts in excess of $100; and (5) every debt
which exceeds your net worth.
.* Signature of Applicant
NOTE: This information will be used to satisfy Equal Employment Opportunity reporting and research requirements.
For office use tP ails7)
QUESTIONNAIRE FOR EXECUTIVE APPOINTMENTS
FOR OFFICE USE ONLY
Office: Bd/Pos No. /__
Date of Appointment: Term Ending: TCD
Type of Appointment: New D Reappointment 0 Unexpired Term 0 Cnty
Hndc._ S_ R
The information from this questionnaire will be used by the GOVERNOR'S OFFICE and, where applicable, the FLORIDA
SENATE in considering action on your confirmation. Please complete each blank on the questionnaire. Please type or use black
* 1 Name: _____
L. Fvot MMkl/M4a4
"* 2. Business Address:
Ste"' Offict x CRy
P... Office Box 5ue Zp CA Am Codk/Ph.. NMber
"*3. Residence Address:
Sbrr Apmrtbend i City
Pasl Otlier B. Stas Zi, Cp d Ar&a Cede/Plamm Nlbume
Please specify the preferred mailing address: Business 0 Residence 0
4. A. List all your places of residence during the last five (5) years.
ADDRESS CITY & 5TATI FROM TO
B. List all your former and current residences outside of Florida that you have maintained at any time during adulthood.
ADDRESS CrrY & STATE FROM TO
5. Date of Birth: _____-...__________ Place of Birth: __-------------
6. Social Security Number: ---------
"7. Driver's License Number: Issuing State: -- -----
9. Are you a United States citizen? Yes 0 No C If "No", please explain:
If you are a naturalized citizen, date of naturalization:
10. Continuous resident of Florida since:
11. Are you a registered Florida voter? Yes 0 No 0 If "Yes", please list:
A. County of registration: B. Party Affiliation:
"* 2. Education
A. High School Year Graduated:
B. List all post-secondary educational institutions attended:
NAME & LOCATION DATES ATTENDED CERTIFICATES/DECREES
13. Are you or have you ever been a member of the armed forces of the United States? Yes 0 No 0 If "Yes", please list:
A. Dates of service:..
B. Branch or component: .
C. Date & type of discharge:
14. Have you ever been arrested, charged or held by federal, state or other law enforcement authorities for violation of any federal
law, state law, county or municipal law, regulation or ordinance? (Exclude traffic violations for which a fine of $100.00 or less
was imposed.) Yes 0 No 0 If "Yes", give details:
DATE PLACE NATURE DISPOSITION
15. A. State your experiences and interests or elements of your personal history that qualify you for appointment. If you are an
office holder, please provide that information, too.
"* B. Have you received degrees, professional certifications or designations related to the subject matter of this office?
Yes 0 No 0 If "Yes", please list.
*15. C. Have you received any awgau or recogniuons reaMing to tnia uml :; ,, s...-.v .. .., .. ...
D. Identify all association memberships and offices held by you that relate to this appointment.
*16. Do you currently hold an office or position (appointive, civil service or other) with the federal or any foreign government?
Yes D No 0 If "Yes", please explain.
"*17. A. Have you ever been elected or appointed to any public office in this state? Yes 0 No 0 If "Yes", please state the
office title, date of election or appointment, term of office, and level of government (city, county, district, state, federal):
DATE OF SELECTION
OFFICE TITLE OH APPOINTMENT TERM OF OFI'Ct' LEVEL OF GOVERNMENT
B. If your service was on any appointed boardss, commissions) or councilss:
(1) How often were scheduled meetings?
(2) If you did not attend all of the regularly scheduled meetings, please state the number of such meetings you attended and
the number you missed with the reasons) for your absencess.
18. Have you ever been suspended from any office by the Governor of the State of Florida? Yes 1 No 0 If "Yes", please list:
A. Title of office: C. Reason for suspension:
B. Date of suspension: D. Result: Reinstated 0 Removed O Resigned D
19. Have you ever before been appointed to any office that required confirmation by the Florida Senate? Yes 1 No O
If "Yes", please list:
A. Title of office:..
B. Term of appointment:
C. Confirmation results:.._
20. Have you been a registered lobbyist at any time during the past five (5) years? Yes 0 No 0 If "Yes",:
A. Did you receive any compensation? Yes 7 No 0D
B. Name the entity you represented:
21. If you are appointed, do you know of any reason whatsoever why you will not be able to attend fully to the duties of the office or
position to which you have been appointed? Yes 1 No D If "Yes", please explain:
"* 22. List your present place of ernm)r*ment and all places of employment for the prevo' five (5) years.
EMPLOYER TYPE OF BUSINESS POS, 4 FROM TO
23. Have you ever been employed by any Florida state or local government entity or agency? Yes D No 0 If "Yes", please
identify the positionss, the name(s) of the employer agency and the periods) of employment.
POSITION EMPLOYER AGENCY PERIOD OF EMPLOYMENT
24. Have you ever held a license or certificate? Yes D No If "Yes", please provide the tide, issue date and issuing authority.
If any disciplinary action (fine, probation, suspension, revocation) has been taken, please state the type and date of the action
LICENE/CERTIF. TITLE ISSUE DATE ISSUING AUTHORITY DISCIP. ACTION/DATE
25. To your knowledge, have you, members of your immediate family, or businesses of which you or members of your immediate
family have been an owner, officer or employee, held any contractual or other direct dealings during the last three (3) years with
any Florida state or local governmental agency, including the office or agency to which you are seeking appointment?
Yes O NoO If "Yes", please explain:
BUSINE55 YOUR RELATION TO BUSINESS BUSINESS RELATION TO AGENCY
26. Have you ever been refused a fidelity, surety or other bond? Yes 0 No 0 If "Yes", please explain.
27. Please list three persons who have known you well within the past five (5) years. Include a current, complete address and the
capacity in which they know you. Exclude relatives, employees in the Office of the Governor and members of the Florida Senate.
NAMF. ADDRESS ZIP CODE CAPACITY
28. Name any business, professional, civic or fraternal organizations) of which you are now a member, or of which you have been a
member during the past five (5) years, the addresses) and date(s) of your membershipss.
AM_ ADDRESS ZiP CODE DATE
4 (Rr.tAd 12/tH3)
"THIS PACE ONLY FOR OFFICES REQUIRING CONFIRMATION BY THE FLORIDA SENATE
Pleas* send a copy of this completed questionnaire to the Governor's Office. You may wish to retain the original
for use by the Florida Senate. The Secretary of Sotle's Office will notify you when you should update this
information and have it notarized.
STATE OF FLORIDA, COUNTY OF
Before me, the undersigned Notary Public of Florida, personally appeared
S..., who, after being
duly sworn, says: (1) that he/she has carefully and personally prepared or
read the answers to the foregoing questions; (2) that the information con-
tained in said answers is complete and true; and (3) that he/she will, if
confirmed, fully support the Constitution of the United States and of the State
SiWnsunt at AppLra -Allanl
Sworn to, acknowledged and subscribed before me
this ._ day of 19_ .
-Notary Pllse, kr Al of Mlnd& at ILrge
My commission express: ....
5 Rq,,i.. IZt1H31