2. Committee Member Application Form

   The City of Hallandale Beach is a public entity subject to Chapter 119 of the Florida Statutes concerning public records. Please be advised that all submitted Board and Committee applications are a public record and therefore subject to the disclosure provisions of Chapter 119 of the Florida Statutes.

4. APPLICANT'S INFORMATION
6. LAST NAME:*
7. FIRST NAME*
9. CONTACT NUMBER:*
11. EMAIL:*
13. Address1
15. Address2
17. City
18. State
19. Zip
21. OCCUPATION:
23. If applicable, how long have you lived in Hallandale Beach?
25. VERIFICATION OF RESIDENCY:*

    1. Driver’s License (Required)
    2. Voter’s Registration Card (Required)
    3. Verification of good standing with the City of Hallandale Beach: (No outstanding Liens, Taxes, Open Permits, Utility Balances, Code Cases, Pending Litigation )
27. On the questionnaire below, please select any category which may apply to you. Identity of the applicant is confidential and compliance is strictly voluntary. Information will be used solely to comply with the reporting requirements of Section 760.80, Florida Statutes.
29. PHYSICAL DISABILITY

    1. Yes
    2. No
30. GENDER

    1. Female
    2. Male
32. RACE

    1. African-American
    2. Hispanic-American
    3. Asian-American
    4. Native American
    5. Caucasian
    6. Other
34. Please choose your first, second, and third choices among the following Boards and Committees. If you are interested in only one, this should be indicated.
    (At any given time, board members may not serve on more than one board and one committee or on two boards or on two committees)
36. Committees

    1. Charter Review Committee
    2. Civil Service Board
    3. Golden Isles Safe Neighborhood Advisory Board
    4. Parks & Recreation Advisory Board
    5. Planning & Zoning Board

    1. Police/Fire Pension Board
    2. Public Transportation, Traffic and Parking Advisory Board
    3. Sustainability and Flood Mitigation Advisory Board
    4. Three Islands Safe Neighborhood Advisory Board
    5. Unsafe Structures Board
38. *Required Member Qualification. **Required Statement of Financial Interest (Form 1). The following Board/Committee members are required to disclose their Financial Interest (Form 1) annually: All Board/Committee members are subject to Sunshine Law training.
40. Please tell us about yourself (education, profession, personal accomplishments, honors received, hobbies), list your experience relevant to the committee(s) you are applying for, and provide a brief statement outlining why you wish to serve on the committee(s) you have selected above.
42. PLEASE TELL US ABOUT YOURSELF
44. Signature of Applicant:
45. Date:
47. Last Name:
48. First Name:
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field