Title: Questionnaire for Gubernatorial Appointments
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Permanent Link: http://ufdc.ufl.edu/WL00001331/00001
 Material Information
Title: Questionnaire for Gubernatorial Appointments
Physical Description: Book
Language: English
 Subjects
Spatial Coverage: North America -- United States of America -- Florida
 Notes
Abstract: Questionnaire for Gubernatorial Appointments
General Note: Box 8, Folder 3 ( Vail Conference, 1993 - 1993 ), Item 45
Funding: Digitized by the Legal Technology Institute in the Levin College of Law at the University of Florida.
 Record Information
Bibliographic ID: WL00001331
Volume ID: VID00001
Source Institution: Levin College of Law, University of Florida
Holding Location: Levin College of Law, University of Florida
Rights Management: All rights reserved by the source institution and holding location.

Full Text









QUESTIONNAIRE


for


,,GUBERNATORIAL


APPOINTMENTS


*


I


^------------~-


L608







FOR THE GOVERNOR'S APPOINTMENT OFFICE
The Capitol, Tallahassee, FL 32399-0001
The information from this page has been requested: ard 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 cocitions?
explain.


*4. Sex: Male 0 Female 0

*5. Race: White, non-Hispanic (W) E
Hispanic (H) C
Black (B) C


Yes [ No O If "Yes", please


American Indian/Alaskan Native (A)
Asian/Pacific Islander (P)


6. Do you now, or have you, within the last three )e-ars, been a member of any club or organization that, to
your knowledge, in practice or policy, restricts mer-cership or restricted membership during the time that you
belonged on the basis of race, religion, national crr. or gender? If so, detail the name and nature of the
club(s) or organizations(s), relevant policies and prs cces, and state whether you intend to continue as a
f member if you are appointed by the Governor.



7. Are you willing to file financial disclosure states-cts while serving in an appointed
position? Yes O No C
NOTE: Filing financial disclosure statements gene-,=ly 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 yo-r 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.




APPLICANT'S SIGNATURE



*This information will be used to provide demogracric statistics and is not requested for the purposes of
discriminating on any basis.







b.ol












QUESTIONNAIRE FOR GUBERNATORIAL APPOINTMENTS



FOR OFFICE USE ONLY
T


Office:

Date of Appointment: Term Ending:

Type of Appointment: New D Reappointment 0 Unexpired Term 0


1. Name:
Mr/Mrs/Ms.

2. Business Address:


DATE COMPLETED


FIRST


STREET


OFFICE *


MIDDLE/MAIDEN


CITY


POST OFFICE BOX STATE ZIP CODE AREA CODE/PHONE NUMBER

Residence Address:
STREET CITY COUNTY

POST OFFICE BOX STATE ZIP CODE AREA CODE/PHONE NUMBER


Specify the preferred mailing address: Business O Residence D

4. A. List all your places of residence during the last five (5) years.
ADDRESS CTY & STATE


FROM TO


B. List all your former and current residences outside of Florida that you have marained at any time during adulthood.
ADDRESS C,"Y & STATE FROM TO








5. Date of Birth: Place of Birth:

6. Social Security Number:

7. Driver's License Number: issuing State:

8. Have you ever used or been known by any other legal name? Yes 0 No D f 'Yes', explain:


Revsed 10/20/92


(0,10


Bcara No.

Pcstion No.

Couy






9. Are you a United States citizen? Yes 0 No 0 If "No'. exosain:


SIf you are a naturalized citizen, date of naturalization:
10. Since what year have you been a continuous resident
11. Are you a registered Florida voter? Yes O No 0
A. County of registration:
12. Education

A. High School
B. List all post-secondary educational institutions atte
NAME & LOCATION


of Floricz


B. Current Party Affiliation:


Year Graduated:


DATS ATTENDED


CER'PCATES/DEGREES RECEIVED


13. Are you or have you ever been a member of the armed forces of the United States? Yes 2 No 0 If "Yes", lis:
A. Dates of service:
B. Branch or component:
C. Date & type of discharge:
14. Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, recjuaion,
or ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less was paid.) Yes 0 No If
"Yes', give details:
DATE PLACE NATURE DISPOS-ON




15. Concerning your current employer and for all of your employment during the last five years. list your employer's rare,
business address, type of business, occupation or job title, anc periods) of employment
EMPLOYER'S NAME AND ADDRESS TYPE OF BUSINESS OCCUPATIONIJOE -.L.E PERIOD OF EMP,.-VENT









16. Have you ever been employed by any state, district, or local gcovemmental agency in Flor:a? Yes O No E If
"Yes", identify the positionss, the name(s) of the employing agency, and the periods) of employment:
POSITION EMPLC''ING AGENCY PERIOD OF EMPLOYV_.-





r "" """ "^


Revised 10/20/92


(.I1


Sr








17. A. State your experiences and interests or elements of your personal history that qualify you for this appointment.


B. Have you received any degreess, professional certificationss, or designations) related to the subject matter of this
appointment? Yes 0 No 0 If "Yes', list








C. Have you received any awards or recognition relating to the subject matter of this appointment? Yes 0 No 0
If "Yes", list








D. Identify all association memberships and association offices held by you that relate to this appointment:










18. Do you currently hold an office or position (appointive, civil service, or other) with the federal or any foreign
government? Yes O No O If "Yes", explain:










19. A. Have you ever been elected or appointed to any public office in this state? Yes No 0 If "Yes", sate the
office title, date of election or appointment, term of office, and level of government (city, county, district, sta:e,
federal):


DATE OF ELECTION
OR APPOINTMENT


TERM OF OFFICE


LEVEL OF GOVERNhVET.


(,.\I


OFFICE TITLE


Revised 10/20/92






B. If your service was on an appointed boardss, commissionss, committeess, or council(s):
(1) How frequently were meetings scheduled:
(2) If you missed any of the regularly scheduled meetings, state the number of meetings you attended. the number
you missed, and the reasons) for your absence(s).


MEETINGS ATTENDED


MEETINGS MISSED


REASON FOR ABSENCE


20. Has probable cause ever been found that you were in violation of Part III, Chapter 112, F.S., the Code of E--ics for Public
Officers and Employees? Yes 0 No 0 If "Yes", give details:
DATE NATURE OF VIOLATION DISPOSTION






21. Have you ever been suspended from any office by the Governor of the State of Florida? Yes 0 No If "Yes',
list


A. Title of office:


C. Reason for suspension:


B. Date of suspension:


D. Result Reinstated O Removed O Resigned 0


22. Have you previously been appointed to any office that required confirmation by the Florida Senate? Yes -
If "Yes", list


No 0


A. Title of office:
B. Term of appointment:
C. Confirmation results:

23. Have you ever been refused a fidelity, surety, performance, or other bond? Yes O No 0 If "Yes", ex~ain:




24. Have you held or do you hold an occupational or professional license or certificate in the State of
Florida? Yes 0 No 0 If "Yes", provide the title and number, issue date, and issuing authority. If any :=sciplinary
action (fine, probation,suspension, revocation, disbarment) has ever been taken against you by the issuing a_-nority, state
the type and date of the action taken:
UCENSE/CERTFICATE
TTTLE & NUMBER ISSUE DATE ISSUING AUTHORITY DISCIPLINARY ACTION/DATE








25. A. Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or cther direct
dealings during the last four (4) years with any state or local governmental agency in Florida, including the office or
agency to which you have been appointed or are seeking appointment? Yes 0 No O If "Yes", explain:


NAME OF BUSINESS


YOUR RELATIONSHIP TO BUSINESS


BUSINESS' RELATIONSHIP TC aENCY


RWevi 10/20/92


NAME OF BUSINESS


(.13







B. Have members of !cur immediate family (spouse, child, parentss, siblingss), or businesses of which members of your
immediate family trave been owners, officers, or employees, held any contractual or other direct dealings during the
last four (4) years nth any state or local governmental agency in Florida, including the office or agency to which you
have been appointed or are seeking appointment? Yes O No O If "Yes", explain:


NAME OF BUS.'eS


FAMILY MEMBER'S
RELATIONSHIP TO YOU


FAMILY MEMBER'S
RELATIONSHIP TO BUSINESS


BUSINESS' RELATIONSHIP
TO AGENCY


26. Have you been a registered lobbyist or have you lobbied at any level of government at any time during the past five (5)
years? Yes O No Z

A. Did you receive any compensation other than reimbursement for expenses? Yes 0 No C

B. Name the agency cr entity you lobbied and the principals) you represented:


AGENCY LOBBIED


PRINCIPAL REPRESENTED


27. List three persons who have known you well within the past five (5) years. Include a current, complete address and
telephone number. Exclude relatives and members of the Florida Senate.


MAILING ADDRESS


ZIP CODE


28. Name any business. professional, occupational, 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 organization addressess, and date(s) of your
membershipss.


OFFICES) HELD & TERM


29. Do you know of any reason why you will not be able to attend fully to the duties of the office or position to which you
have been or will be appointed? Yes 0 No O If "Yes", explain:








30. If required by law or administrative rule, will you file financial disclosure statements? Yes O NO 0







5
Reviseo 10/20/92


NAME


NAME


ADDRESS


AREA CODE/PHON R


DATES) OF MEMBERSHIP













CERTIFICATION


STATE OF FLORIDA, COUNTY OF

Before me, the undersigned Notary Public of Florida, personally appeared

,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 contained in said answers
is complete and true; and (3) that he/she will, as an appointee, fully support the
Constitutions of Ihe United States and of the State of Florida.


SIGNATURE OF APPUCANT-AFFIANT


Sworn to and subscribed before me


, ^ this dayof ,19 .


SIGNATURE OF NOTARY PUBLIC-STATE OF FLORIDA


(PRINT. TYPE OR STAMP COMMISSIONED NAME OF NOTARY PUBLIC)


My commission expires:


Personally Known 0 OR
Type of Identification Produced


Produced Idenification


(SEAL)


Poised 10/20/92




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