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2. Select the Board, Commission, or Committee applying for*
   -- Select One --Select OneAffordable Housing Advisory CommitteeConstruction Industry Licensing Board/Fire Prevention Code - Board of AppealsIndustrial Development AuthorityLake-Sumter Metropolitan Planning Organization (MPO)Library Advisory BoardNorth Sumter County Utility Dependent District (NSCUDD)OtherPublic Safety Coordinating Council
3. List Other Board Below:
4. Committee's requirements
   Click here to view Committee webpage
6. First Name*
7. Middle
8. Last Name*
10. Address1*
12. Address2
14. City*
15. State*
16. Zip*
18. Are you a resident of Sumter County*

    1. Yes
    2. No
19. If yes, how long?
20. If no, what County
22. Email Address
24. Phone Number*
25. Phone

    1. Mobile
    2. Home
    3. Work
26. Alternate Phone Number
28. Education
30. Occupation*
31. Place of Employment
33. Professional Organizations
35. Civic and Professional Accomplishments
37. Training or experience related to this appointment?
39. What contributions do you feel you could make if you were selected to this committee/board?
41. References
43. 1.
45. 2.
47. 3.
49. Some of the Boards and Committees appointed by the County Commission are required to comply with Chapter 112, Florida Statutes; the Financial Disclosure Law. If applicable, would you be willing to file the required financial statement?*

    1. Yes

    1. No
51. Appointees will be required to attend meetings in accordance with the adopted policies of the County.
53. Do you affirm that your personal and business affairs (if applicable) within Sumter County are in substantial compliance with all county regulatory and taxing authorities rules and regulations?*

    1. Yes

    1. No
55. Attach additional information, such as a resume.
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57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit Submit and Print

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