Volunteer Advisory Board Application

Board(s) applying for*

Hold CTRL Key and Click to select multiple
.
Annual financial disclosure forms may be required. Certain boards require skill-set disciplines. Please see Board pages for specifics.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Upload Proof of Residency

Max. file size: 512 MB.

Do you have a different mailing address?*

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Business Phone

Cell Phone

Email*

List all properties owned and/or business interests in Lake Worth Beach*

What is your occupation?*

Employer?

Business Address: (CRA board only)*

Street Address Address Line 2 City State ZIP Code

Are you currently serving on any City Advisory Board?*

Yes
No

Which Boards?*

Have you ever served on a City of Lake Worth Beach Advisory Board?*

Yes
No

If yes, when and which board(s)?*

Relevant Experience

Interest/Activities

Community Involvement

Why do you desire to serve on this board (first preference)

Why do you desire to serve on this board (second preference)

Why do you desire to serve on this board (third preference)

For Education Task Force, which school do you want to work with?

Consent*

I agree to the privacy policy.

I understand the responsibilities associated with being a board/committee member, and I have adequate
time to serve if appointed.

I have read the attached Ordinance No. 2010-29 and Article XIII (Palm Beach County) Code of Ethics and
understand the policy on the City of Lake Worth Beach Code of Ethics. Within 30 days after appointment, I
understand that I am required to participate in Ethics Training and submit an Acknowledgement of Receipt
form to the City Clerk’s Office in order to continue to serve on my appointed board.

*THIS APPLICATION IS VALID FOR ONE (1) YEAR FROM THE DATE SIGNED.

*THIS APPLICATION IS NOT VALID WITHOUT APPLICANT’S PROOF OF RESIDENCY.

Today's Date

Signature*

Please type your name as it appears in the beginning of the application.

Name

This field is for validation purposes and should be left unchanged.

Volunteer Advisory Board Application

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