Gubernatorial Appointment Toolkit
2014-2015
The AIA Florida Citizen Architect Leadership Program: Gubernatorial Appointment Program (GAP) is an
effort to assist placement of architects in positions of influence in our communities.
For more information conatct AIA Florida Headquarters at 850-222-7590.
AIA Citizen Architect Leadership Program:
Gubernatorial Appointment Program (GAP)
In an effort to grow the influence of the architectural profession, AIA Florida
has developed the Gubernatorial Appointment Program (GAP) to help place
architects in positions of influence within our communities.
The state of Florida currently has greater than 900 appointed positions on
various boards and committees around the state. These appointments are
awarded by the governor’s office throughout the year as seats become vacant.
AIA Florida has identified more than 250 positions for which architects could
provide key insight and leadership. These vary from state regulatory & code
boards, community/regional development boards to local cultural and arts
boards. AIA Florida’s mission is to position architects to lead the shaping of
Florida’s future. To that end, it is vital that the profession be represented on
these boards in order to provide leadership and guidance in all aspects of
business that affect the built environment.
The following toolkit provides each component with all pertinent information
regarding each appointed position in addition to an example application and
links to the Governor’s appointment applications.
It is intended that interested parties will coordinate with AIA Florida to complete
all submittal information. After reviewing the attached application as generated
by the state of Florida, please submit your resume along with responses for
application questions 16-19; as well as responses to questionnaire questions
17-30, to AIA Florida no later than Dec. 5, 2014 for review.
Following the review and comment process, applicants will complete the full
online application and questionnaire to submit to the Office of the Governor. AIA
Florida will then have the opportunity to advocate for your appointment.
Table of Contents
Current Vacancies..................................................................................1
State of Florida Appointment Application................................................10
Questionnaire for Gubernatorial Appointments.......................................20
State of Florida
Governor of list of Board Committee Appointment
2014
Board Name
Children's Trust Governing
Board of Miami-Dade County
Children's Trust Governing
Board of Miami-Dade County
Florida Greenways and Trails
Council
Southeast Volusia Hospital
District
Southeast Volusia Hospital
District
Term
SC*
Appt Date
Exp Date
Incumbent Name
Seat Qualification
4 Years
No
7/18/2011
3/17/2014
Ms. Membiela, Roymi
Seven appointed by the Governor
4 Years
No
7/18/2011
3/17/2014
Mrs. de Moya, Lileana
Seven appointed by the Governor
Mr. Diaz de Villegas,
Roberto
2 Years
No
4 Years
No
6/2/2011
3/31/2014
Mr. Heeb, Ferdinand
4 Years
No
6/22/2011
3/31/2014
Mr. Smothers, Harold
4 Years
No
Vacant
The Governor appoints two members
representing the trail user community.
Governor appoints a resident of the City
of Edgewater effective upon next
vacancy.
Governor appoints a resident of the City
of Oak Hill.
The Governor shall appoint three
members from scientific disciplines
related to land, water or environmental
sciences.
3 Years
Yes
Vacant
Jackson County
Vacant
An elected school board member
nominated by the Florida School Board
Association, appointed by the Governor.
10/18/2013 1/21/2014
Acquisition and Restoration
Council
Apalachee Regional Planning
Council, Region Two
Apalachee Regional Planning
Council, Region Two
Baker County Development
Commission
Baker County Development
Commission
Baker County Development
Commission
3 Years
Yes
4 Years
No
8/23/2005 10/28/2008
Ms. Gore, Polly
County Commission District 4
4 Years
No
10/22/2005 10/21/2009
Ms. D'Ane, Gloriya
Two members from the county at-large.
4 Years
No
11/2/2005
Mrs. Davis, Joyce
County Commission District 5
11/1/2009
*SC= Senate Confirmation
Baker County Development
Commission
Baker County Development
Commission
Baker County Development
Commission
Baker County Hospital
Authority
Baker County Hospital
Authority
Baker County Hospital
Authority
Baker County Hospital
Authority
Baker County Hospital
Authority
Biomedical Research Advisory
Council
Biomedical Research Advisory
Council
Biomedical Research Advisory
Council
Biomedical Research Advisory
Council
Board of Commissioners, North
Broward Hospital District
Board of Commissioners, South
Broward Hospital District
4 Years
No
10/26/2006 10/13/2010
Mr. MANN, RONALD
County Commission District 1
4 Years
No
8/30/2013 10/22/2013 Mr. Gazes, Christopher Two members from the county at-large.
4 Years
No
4 Years
No
10/25/2004
4 Years
No
4 Years
Vacant
County Commission District 2
9/8/2008
Ms. Dedmon, Melba
NA
10/25/2004
9/8/2008
Mrs. Dolan, Karen
NA
No
4/4/2006
12/9/2009
Mr. McKendree, Glenn
NA
4 Years
No
4/4/2006
12/9/2009
Mr. Ferreira, Vincent
NA
4 Years
No
12/10/2006 12/9/2010
3 Years
No
4/19/2010
1/10/2012
3 Years
No
4/20/2010
1/10/2012
3 Years
No
2/27/2009
1/10/2012
Mrs. Gnann, Debra
NA
Governor shall appoint two members
with expertise in the field of biomedical
Mr. Wahlestedt, Claes
research.
Governor shall appoint two members
with expertise in the field of biomedical
Dr. Weissbach, Herbert
research.
Governor shall appoint one member
representing the general population of
Mr. Latimer, Albert
the state.
3 Years
No
Vacant
Governor shall appoint one member
from a research university in the state.
4 Years
No
Vacant
subdistrict #1
4 Years
No
Mr. Jones, Albert
Member must reside in subdistrict #1
7/17/2009
6/30/2011
*SC= Senate Confirmation
Board of County
Commissioners of Glades
County
Board of Trustees, Florida A
and M University
Board of Trustees, Florida
Polytechnic University
Board of Trustees, Florida
School for the Deaf and the
Blind
Board of Trustees, Florida
School for the Deaf and the
Blind
Board of Trustees, Florida
School for the Deaf and the
Blind
Board of Trustees, Florida
Virtual School
Bradford County Development
Authority
Bradford County Development
Authority
Bradford County Development
Authority
Bradford County Development
Authority
Bradford County Development
Authority
Bradford County Development
Authority
Bradford County Development
Authority
Cape Canaveral Hospital
District, Brevard County
4 Years
No
Vacant
N/A
5 Years
Yes
Vacant
4 Years
Yes
Vacant
Six member appointed by the Governor
One member appointed by the
Governor
4 Years
Yes
2/22/2010 11/13/2013 Ms. Rodriguez, Yolanda
5 Lay Members
4 Years
Yes
2/22/2010 11/20/2013
Ms. Ross, Carol
5 Lay Members
4 Years
Yes
Vacant
4 Years
No
Vacant
5 Lay Members
Seven members appointed by the
Governor.
4 Years
No
9/19/1997
Mr. Johns, Charley
Members from county-at-large.
4 Years
No
5/13/1998 11/29/2001
Dr. Berry, Virgil
County Commission District 3
4 Years
No
9/6/2000
7/20/2004
Mr. Biggs, James
Members from county-at-large.
4 Years
No
9/6/2000
9/5/2004
Mrs. Starling, Janet
County Commission District 2
4 Years
No
Vacant
County Commission District 1
4 Years
No
Vacant
County Commission District 4
4 Years
No
Vacant
County Commission District 5
4 Years
No
Mr. Fischer, Russell
NA
12/7/2007
7/24/2001
8/19/2011
*SC= Senate Confirmation
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Cape Canaveral Hospital
District, Brevard County
Central Florida Regional
Planning Council, Region Seven
Central Florida Regional
Planning Council, Region Seven
Central Florida Regional
Planning Council, Region Seven
Central Florida Regional
Planning Council, Region Seven
4 Years
No
12/7/2007
8/19/2011
Mr. Anderson, John
NA
4 Years
No
12/7/2007
8/19/2011
Mr. Ragland, Charles
NA
4 Years
No
12/7/2007
8/19/2011
Dr. Ross, David
NA
4 Years
No
12/7/2007
8/19/2011
Mrs. George, Judith
NA
4 Years
No
12/7/2007
8/19/2011
Mrs. Teran, Monica
NA
4 Years
No
9/24/2009
8/19/2013
Mr. Bray, Ronald
NA
4 Years
No
9/24/2009
8/19/2013
Dr. Von Thron, Joseph
NA
4 Years
No
9/24/2009
8/19/2013
Mr. Kabboord, John
NA
4 Years
No
9/24/2009
8/19/2013
Ms. Schenck, Barbara
NA
4 Years
No
9/24/2009
8/19/2013
Mrs. Lee, Rhonda
NA
4 Years
No
9/24/2009
8/19/2013
Dr. Flom, Elena
NA
3 Years
Yes
4/13/2009
10/1/2010 Mrs. Tucker, Jacqueline
Desoto County
3 Years
Yes
4/23/2012
10/1/2013 Mr. Huddleston, Chester
Hardee County
3 Years
Yes
2/6/2013
10/1/2013 Mr. Goodman, Marshall
Polk County
3 Years
Yes
Vacant
*SC= Senate Confirmation
Highlands County
Central Florida Regional
Planning Council, Region Seven
Central Florida Regional
Planning Council, Region Seven
3 Years
Yes
Vacant
Okeechobee County
3 Years
Yes
Vacant
Polk County
Vacant
A representative nominated by
Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
Vacant
A representative of the appropriate
water management district or districts.
(Ex-officio member)
Vacant
A representative of the appropriate
water management district or districts.
(Ex-officio member)
Central Florida Regional
Planning Council, Region Seven
3 Years
Yes
Central Florida Regional
Planning Council, Region Seven
3 Years
Yes
Central Florida Regional
Planning Council, Region Seven
3 Years
Yes
3 Years
Yes
Vacant
An elected school board member
nominated by the Florida School Boardd
Association, appointed by the Governor.
4 Years
Yes
Vacant
NA
4 Years
Yes
Vacant
NA
4 Years
Yes
8/20/2013 10/31/2013
Four General Contractors
4 Years
Yes
8/20/2013 10/31/2013
Mr. Del Vecchio, Paul
Mr. Dachepalli,
Badarinath
4 Years
Yes
4 Years
Yes
Central Florida Regional
Planning Council, Region Seven
Citrus County Hospital Board
Citrus County Hospital Board
Construction Industry Licensing
Board
Construction Industry Licensing
Board
Construction Industry Licensing
Board
District Board of Trustees,
Chipola College
8/21/2007
5/31/2011
Vacant
Two Lay Members
Three Building or Residential
Contractors, at least one of each.
Mrs. Page, Jan
Washington County
*SC= Senate Confirmation
District Board of Trustees,
Chipola College
District Board of Trustees,
Chipola College
District Board of Trustees,
Chipola College
District Board of Trustees,
Florida Gateway College
District Board of Trustees,
Florida Gateway College
District Board of Trustees,
Florida Gateway College
District Board of Trustees,
Florida Gateway College
District Board of Trustees,
Florida Gateway College
District Board of Trustees,
Florida Gateway College
District Board of Trustees,
Indian River State College
District Board of Trustees,
Indian River State College
District Board of Trustees,
Indian River State College
District Board of Trustees, LakeSumter State College
District Board of Trustees, LakeSumter State College
District Board of Trustees,
North Florida Community
College
District Board of Trustees,
North Florida Community
College
4 Years
Yes
8/3/2009
5/31/2013
Mrs. Stuart, Virginia
Jackson County
4 Years
Yes
8/3/2009
5/31/2013
Mr. Ryals, Daniel
Calhoun County
4 Years
Yes
8/3/2009
5/31/2013
Dr. Bailey, Leisa
Holmes County
4 Years
Yes
6/4/2007
5/31/2010
Mrs. Wall, Harriet
Dixie County
4 Years
Yes
8/30/2007
5/31/2011
Mrs. Randolph, Athena
Columbia County
4 Years
Yes
8/30/2007
5/31/2011
Mr. Riherd, Thomas
Union County
4 Years
Yes
8/17/2009
5/31/2013
Mrs. Norris, Suzanne
Columbia County
4 Years
Yes
8/17/2009
5/31/2013
Mrs. Richardson, Julia
Baker County
4 Years
Yes
8/17/2009
5/31/2013
Ms. McInnis, Kathryn
Dixie County
4 Years
Yes
8/21/2007
5/31/2011
Mr. Bols, Werner
Martin County
4 Years
Yes
8/18/2009
5/31/2013
Ms. Rowley, Jane
St. Lucie County
4 Years
Yes
8/18/2009
5/31/2013
Mrs. Davis, Vicki
Martin County
4 Years
Yes
9/11/2007
5/31/2011
Dr. Kelly, Kenneth
Sumter County
4 Years
Yes
9/2/2009
5/31/2013
Mrs. Odom, Margo
Lake County
4 Years
Yes
8/30/2007
5/31/2010 Mr. Helvenston, Brantly
Suwannee County
4 Years
Yes
5/20/2009
5/31/2010
Suwannee County
Dr. Brothers, William
*SC= Senate Confirmation
District Board of Trustees,
North Florida Community
College
District Board of Trustees,
Northwest Florida State
College
District Board of Trustees,
Northwest Florida State
College
District Board of Trustees,
Northwest Florida State
College
District Board of Trustees,
Northwest Florida State
College
District Board of Trustees,
Northwest Florida State
College
District Board of Trustees, Palm
Beach State College
District Board of Trustees,
Pasco-Hernando Community
College
District Board of Trustees,
Pasco-Hernando Community
College
District Board of Trustees,
Pensacola State College
District Board of Trustees, Polk
State College
District Board of Trustees, Polk
State College
District Board of Trustees,
Santa Fe College
4 Years
Yes
Vacant
Hamilton County
4 Years
Yes
8/6/2007
5/31/2011
Mr. Pennington, Brian
Okaloosa County
4 Years
Yes
7/15/2009
5/31/2013
Mrs. Strauss, Mary
Okaloosa County
4 Years
Yes
7/15/2009
5/31/2013
Ms. Gillis, Rachel
Walton County
4 Years
Yes
Vacant
Okaloosa County
4 Years
Yes
Vacant
Okaloosa County
4 Years
Yes
7/15/2009
5/31/2013
Mr. Talley, David
Palm Beach County
4 Years
Yes
6/4/2007
5/31/2010
Ms. Gavish, Jeanne
Hernando County
4 Years
Yes
7/15/2009
5/31/2013
Mr. Di Rienzo, John
Hernando County
4 Years
Yes
7/15/2009
5/31/2013
Mr. O'Connor, John
Santa Rosa County
4 Years
Yes
8/26/2009
5/31/2013
Mrs. Martinez, Teresa
NA
4 Years
Yes
8/26/2009
5/31/2013
Mr. Pinner, Ernest
NA
4 Years
Yes
7/15/2009
5/31/2013
Dr. Jackson, Bessie
Alachua County
*SC= Senate Confirmation
District Board of Trustees,
Santa Fe College
District Board of Trustees,
Tallahassee Community College
District Board of Trustees,
Tallahassee Community College
District Board of Trustees,
Tallahassee Community College
East Central Florida Regional
Planning Council, Region Six
East Central Florida Regional
Planning Council, Region Six
East Central Florida Regional
Planning Council, Region Six
East Central Florida Regional
Planning Council, Region Six
East Central Florida Regional
Planning Council, Region Six
East Central Florida Regional
Planning Council, Region Six
East Central Florida Regional
Planning Council, Region Six
4 Years
Yes
7/15/2009
5/31/2013
Mr. McRae, Arley
Bradford County
4 Years
Yes
9/15/2009
5/31/2013
Dr. Callen, Dana
Leon County
4 Years
Yes
9/15/2009
5/31/2013
Mr. DeFoor, J. Allison
Wakulla County
4 Years
Yes
Vacant
Gadsden County
3 Years
Yes
3/18/2010
10/1/2012
Mr. Glover, Robert
Brevard County
3 Years
Yes
3/18/2010
10/1/2012
Mr. Lesman, John
Orange County
3 Years
Yes
Vacant
Lake County
3 Years
Yes
Vacant
Osceola County
3 Years
Yes
Vacant
Brevard County
3 Years
Yes
Vacant
Volusia County
3 Years
Yes
Vacant
A representative of the Department of
Transportation. (Ex-officio member)
*SC= Senate Confirmation
Vacant
A representative of the appropriate
water management district or districts.
(Ex-officio member)
An elected school board member
nominated by the Florida School Boardd
Association, appointed by the Governor.
East Central Florida Regional
Planning Council, Region Six
3 Years
Yes
East Central Florida Regional
Planning Council, Region Six
Florida Building Code
Administrators and Inspectors
Board
3 Years
Yes
Vacant
4 Years
Yes
Vacant
4 Years
Yes
Vacant
Two members serving as an inspector.
Residential Contractor licensed to do
business in Florida and actively engaged
in profession.
3 Years
Yes
Vacant
NAA
4 Years
No
Ms. Maldonado, Alci
Governor shall appoint 4 members.
4 Years
No
Mrs. Wall, Barbara
Governor shall appoint 4 members.
4 Years
No
Vacant
Governor shall appoint 4 members.
4 Years
No
Vacant
4 Years
Yes
4 Years
No
4 Years
No
4 Years
No
Florida Building Commission
Florida Commission on
Community Service
Florida Commission on the
Status of Women
Florida Commission on the
Status of Women
Florida Commission on the
Status of Women
Florida Commission on the
Status of Women
Florida Communities Trust
Florida Council on Arts and
Culture
Florida Council on Arts and
Culture
Florida Council on Arts and
Culture
10/15/2008 9/30/2011
2/1/2010
9/30/2013
Governor shall appoint 4 members.
Governor shall appoint a former elected
official of a metropolitan municipal
Vacant
government.
Seven members appointed by the
10/5/2010 12/31/2010 Ms. Wester, Elizabeth
Governor.
Seven members appointed by the
6/23/2008 12/31/2010
Mr. Judd, Robert
Governor.
Seven members appointed by the
10/5/2010 12/31/2013 Mrs. Townsend, Kathryn
Governor.
*SC= Senate Confirmation
Florida Council on Arts and
Culture
Florida Council on Arts and
Culture
Florida Council on Arts and
Culture
Florida Development Finance
Corporation
Florida Development Finance
Corporation
Florida Major Performing Arts
Center Task Force
Florida Real Estate Appraisal
Board
Florida Real Estate Appraisal
Board
4 Years
No
10/5/2010 12/31/2013
The Honorable
Deratany, Timothy
4 Years
No
10/5/2010 12/31/2013
Mr. Lochrie, Glenn
4 Years
No
Vacant
4 Years
Yes
Vacant
4 Years
Yes
Vacant
1 Year
No
Vacant
4 Years
Yes
Vacant
4 Years
Yes
Vacant
NA
One of the directors shall be an
economic development specialist.
The Governor shall appoint one
member from among the cultural
community leadership.
Two Licensed or Certified Residential
Real Estate Appraisers.
Two members of the general public who
are not connected in any way with real
estate appraisal.
Vacant
At least one representative of a parent
training and information center,
pursuant to s. 671 of the Individuals
with Disabilities Education Act.
Florida Rehabilitation Council
3 Years
No
3 Years
No
Vacant
At least one representative who is a
director of a Vocational Rehabilitation
Service Project for American Indians
with Disabilities under s. 121.
4 Years
No
Vacant
Member from the private sector
4 Years
No
Vacant
NA
Florida Rehabilitation Council
Florida Small Business
Development Center Network
Statewide Advisory Board
Gilchrist County Housing
Authority
Seven members appointed by the
Governor.
Seven members appointed by the
Governor.
Seven members appointed by the
Governor.
*SC= Senate Confirmation
Governor's Mansion
Commission
Governor's Mansion
Commission
Governor's Mansion
Commission
Governor's Panel on Excellence
in Long-Term Care
Hamilton County Development
Authority
Hamilton County Development
Authority
Hamilton County Development
Authority
Hamilton County Memorial
Hospital Board
Hamilton County Memorial
Hospital Board
Hamilton County Memorial
Hospital Board
Hamilton County Memorial
Hospital Board
Hamilton County Memorial
Hospital Board
Harbor Master for Port of Fort
Pierce, Saint Lucie County
Hernando County Housing
Authority
Higher Education Facilities
Financing Authority
4 Years
Yes
2/3/2011
9/30/2013
Mrs. Graham, Adele
Governor's Appointment
4 Years
Yes
2/3/2011
9/30/2013
Mrs. Aurell, Jane
Governor's Appointment
4 Years
Yes
Vacant
Governor's Appointment
Vacant
Governor shall appoint a consumer
advocate for senior citizens.
One member shall represent County
Commission District 2
One member shall represent County
Commission District 1
4 Years
No
4 Years
No
4 Years
No
Vacant
4 Years
No
4 Years
No
10/19/2005 1/22/2008
Vacant
Mrs. Williams,
Jacqueline
4 Years
No
10/19/2005 1/22/2009 Dr. Norris, W. Benjamin
NA
4 Years
No
2/16/2006
1/22/2010
Mrs. Tompkins, Amelia
NA
4 Years
No
2/16/2006
1/22/2010
Mrs. Daniels, Ida
NA
4 Years
No
Vacant
NA
2 Years
Yes
Mr. Porter, Jesse
NA
4 Years
No
Vacant
5 Years
Yes
Vacant
NA
Five members appointed by the Gov
including an empl or dir, etc, of an
institution of higher ed.
10/8/2010
6/6/2005
9/11/2013
4/4/2007
Mr. Cloyd, John
*SC= Senate Confirmation
Three members at-large
NA
Highlands County Housing
Authority
Hillsborough County Civil
Service Board
Indian River County Housing
Authority
Indian River County Housing
Authority
Investment Advisory Council
Metropolitan Planning
Organization of Miami-Dade
County
Metropolitan Planning
Organization of Miami-Dade
County
Metropolitan Planning
Organization of Miami-Dade
County
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
4 Years
No
Vacant
NA
4 Years
Yes
Vacant
NA
4 Years
No
Vacant
NA
4 Years
No
Vacant
NA
4 Years
Yes
Vacant
N/A
4 Years
No
Mrs. Hantman, Perla
Governor appoints a school board
member.
4 Years
No
Vacant
4 Years
No
Vacant
3 Years
Yes
12/17/2009 10/1/2010 Mr. Montgomery, James
Columbia County
3 Years
Yes
12/17/2009 10/1/2010
Mrs. Haas, Sandra
Suwannee County
3 Years
Yes
12/17/2009 10/1/2012
Mr. Eubank, F. Wesley
Alachua County
3 Years
Yes
12/17/2009 10/1/2012
Mrs. Thomas, Lorene
Dixie County
3 Years
Yes
12/17/2009 10/1/2012
Mr. Williams, Charles
Hamilton County
3/11/2010 12/16/2013
*SC= Senate Confirmation
Governor appoints an elected official
from a municipality within the county.
Governor appoints a person who does
not hold an elected office & reside in
unincorp. area of county
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
North Central Florida Regional
Planning Council, Region 3
3 Years
Yes
12/17/2009 10/1/2012
Mr. Williams, Michael
Madison County
3 Years
Yes
12/17/2009 10/1/2012
Mr. Smith, Andrew
Union County
3 Years
Yes
Vacant
Alachua County
3 Years
Yes
Vacant
Alachua County
3 Years
Yes
Vacant
Alachua County
3 Years
Yes
Vacant
Bradford County
3 Years
Yes
Vacant
Gilchrist County
3 Years
Yes
Vacant
Taylor County
North Central Florida Regional
Planning Council, Region 3
3 Years
Yes
Vacant
3 Years
Yes
Vacant
North Central Florida Regional
Planning Council, Region 3
*SC= Senate Confirmation
A representative nominated by
Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
An elected school board member
nominated by the Florida School Board
Associationn, appointed by the
Governor.
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
Northeast Florida Regional
Planning Council, Region Four
3 Years
Yes
3/26/2009
10/1/2010
Mrs. Brown, Elaine
Duval County
3 Years
Yes
2/19/2010
10/1/2012
Mr. Register, Darryl
Baker County
3 Years
Yes
2/19/2010
10/1/2012
Mr. Sgroi, Robert
Flagler County
3 Years
Yes
2/19/2010
10/1/2012
Mr. Williams, Larry
Nassau County
3 Years
Yes
Vacant
St. Johns County
3 Years
Yes
Vacant
Clay County
3 Years
Yes
Vacant
St. Johns County
3 Years
Yes
Vacant
Clay County
3 Years
Yes
Vacant
Duval County
Vacant
A representative nominated by
Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
Northeast Florida Regional
Planning Council, Region Four
3 Years
Yes
*SC= Senate Confirmation
Vacant
An elected school board member
nominated by the Florida School Board
Association, appointed by the Governor.
Vacant
Council members have distinguished
backgrounds in business, finance, and
public service.
Vacant
Representative of the swimming pool
industry.
Northeast Florida Regional
Planning Council, Region Four
3 Years
Yes
Participant Local Government
Advisory Council
4 Years
Public Swimming and Bathing
Facilities Advisory Review
Board
Rehabilitation Council for the
Blind
School Board of Baker County
School Board of Highlands
County
School Board of Seminole
County
South Florida Regional Planning
Council, Region Eleven
South Florida Regional Planning
Council, Region Eleven
South Florida Regional Planning
Council, Region Eleven
South Florida Regional Planning
Council, Region Eleven
4 Years
Yes
No
3 Years
No
Vacant
The director of the division, who shall
be an ex officio member of the council.
4 Years
No
Vacant
District 3
4 Years
No
Vacant
District 5
2 Years
No
Vacant
District 1
3 Years
Yes
Mrs. Asseff, Patricia
Broward County
3 Years
Yes
Vacant
Broward County
3 Years
Yes
Vacant
3 Years
Yes
Vacant
4/23/2012
10/1/2013
*SC= Senate Confirmation
A representative of the Department of
Transportation. (Ex-officio member)
A representative of the Department of
Environmental Regulation. (Ex-officio
member)
Vacant
A representative nominated by
Enterprise Florida, Inc. and OTTED as an
ex-officio nonvoting member.
Vacant
An elected school board member
nominated by the Florida School Board
Association, appointed by the Governor.
South Florida Regional Planning
Council, Region Eleven
3 Years
Yes
South Florida Regional Planning
Council, Region Eleven
South Lake County Hospital
District Board of Trustees
South Lake County Hospital
District Board of Trustees
South Lake County Hospital
District Board of Trustees
Southeast Volusia Hospital
District
Southeast Volusia Hospital
District
Southwest Florida Regional
Planning Council, Region Nine
Southwest Florida Regional
Planning Council, Region Nine
Southwest Florida Regional
Planning Council, Region Nine
Southwest Florida Regional
Planning Council, Region Nine
Southwest Florida Regional
Planning Council, Region Nine
3 Years
Yes
4 Years
Yes
10/11/2007
7/5/2011
Mr. Drawdy, Rodney
NA
4 Years
Yes
10/11/2007
7/5/2011
Dr. Hari, Aashiv
NA
4 Years
Yes
4/23/2012
7/5/2013
Mr. Rountree, Paul
4 Years
No
6/10/2009
4 Years
No
NA
Governor appoints a resident of the City
3/31/2013 Mr. DeSimone, Thomas
of New Smyrna Beach.
Governor appoints a resident of the City
Vacant
of New Smyrna Beach.
3 Years
Yes
5/13/2009
10/1/2011
Mr. Mazzarantani,
George
Sarasota County
3 Years
Yes
4/23/2012
10/1/2013
Ms. Holquist, Laura
Lee County
3 Years
Yes
Vacant
Lee County
3 Years
Yes
Vacant
3 Years
Yes
Vacant
Sarasota County
An elected school board member
nominated by the FL Sch Bd Assn,
appointed by the Governor.
*SC= Senate Confirmation
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
Tampa Bay Regional Planning
Council, Region Eight
3 Years
Yes
7/17/2007
10/1/2009
Other Bittner, Linda
Pinellas County
3 Years
Yes
4/23/2012
10/1/2012
Mrs. Vance, Kim
Hillsborough County
3 Years
Yes
6/21/2011
10/1/2012
Mr. Young, Earl
Pasco County
3 Years
Yes
4/23/2012
10/1/2013
Mr. Schock, Timothy
Hillsborough County
3 Years
Yes
2/1/2012
10/1/2013
Ms. Todd, Barbara
Pinellas County
3 Years
Yes
Vacant
Hillsborough County
3 Years
Yes
Vacant
Manatee County
3 Years
Yes
Vacant
Pinellas County
3 Years
Yes
Vacant
Position Not Needed - Pinellas County
3 Years
Yes
Vacant
Pasco County
3 Years
Yes
Vacant
Hillsborough County
*SC= Senate Confirmation
Tampa Bay Regional Planning
Council, Region Eight
3 Years
Yes
Vacant
Mr. Shipp, Lawrence
An elected school board member
nominated by the Florida School Board
Association, appointed by the Governor.
Representative of Seat Three appointed
by the Governor.
No
Vacant
NA
4 Years
No
Vacant
NA
4 Years
No
Vacant
NA
4 Years
No
Vacant
NA
4 Years
No
Vacant
NA
3 Years
Yes
3/26/2009
10/1/2010
Mr. Davis, Michael
Palm Beach County
3 Years
Yes
4/23/2012
10/1/2013
Mr. Stork, Robert
Indian River County
3 Years
Yes
4/23/2012
10/1/2013
Mr. Sachs, Peter
Palm Beach County
Tampa Bay Regional Planning
Council, Region Eight
Tampa Port Authority
Technological Research and
Development Authority,
Brevard County
Technological Research and
Development Authority,
Brevard County
Technological Research and
Development Authority,
Brevard County
Technological Research and
Development Authority,
Brevard County
Technological Research and
Development Authority,
Brevard County
Treasure Coast Regional
Planning Council, Region Ten
Treasure Coast Regional
Planning Council, Region Ten
Treasure Coast Regional
Planning Council, Region Ten
A representative of the appropriate
water management district or districts.
(Ex-officio member)
3 Years
Yes
4 Years
Yes
4 Years
Vacant
1/27/2010 11/25/2013
*SC= Senate Confirmation
Treasure Coast Regional
Planning Council, Region Ten
3 Years
Yes
Vacant
Palm Beach County
3 Years
Yes
Vacant
Palm Beach County
3 Years
Yes
Vacant
St. Lucie County
Vacant
A representative of the appropriate
water management district or districts.
(Ex-officio member)
Vacant
A representative of the appropriate
water management district or districts.
(Ex-officio member)
Vacant
A representative of the appropriate
water management district or districts.
(Ex-officio member)
Yes
Vacant
An elected school board member
nominated by the Florida School Board
Association, appointed by the Governor.
West Florida Regional Planning Pleasure
of the
Council, Region One
Governor
Yes
Vacant
Walton County
West Florida Regional Planning Pleasure
of the
Council, Region One
Governor
Yes
Vacant
Okaloosa County
Treasure Coast Regional
Planning Council, Region Ten
Treasure Coast Regional
Planning Council, Region Ten
Treasure Coast Regional
Planning Council, Region Ten
3 Years
Yes
Treasure Coast Regional
Planning Council, Region Ten
3 Years
Yes
Treasure Coast Regional
Planning Council, Region Ten
3 Years
Yes
Treasure Coast Regional
Planning Council, Region Ten
3 Years
*SC= Senate Confirmation
4 Years
No
7/26/2010
9/26/2011
Ms. Dupee, Ann
4 Years
No
7/26/2010
9/26/2011
Mr. Welch, Jeffrey
4 Years
No
7/26/2010
9/26/2013
Mr. Tua, Feliberto
An elected school board member
nominated by the FL Sch Bd Assn,
appointed by the Governor.
Three members appointed by the
Governor.
Three members appointed by the
Governor.
Three members appointed by the
Governor.
3 Years
Yes
7/13/2007
10/1/2009
Mr. Kelly, Edward
Marion County
3 Years
Yes
11/15/2007 10/1/2010
Mr. Abshier, R. Edward
Marion County
3 Years
Yes
10/1/2010
Mrs. Hanson, Martha
Marion County
3 Years
Yes
Vacant
Citrus County
3 Years
Yes
Vacant
Hernando County
3 Years
Yes
Vacant
Levy County
3 Years
Yes
Vacant
3 Years
Yes
Vacant
Sumter County
An elected school board member
nominated by the FL Sch Bd Assn,
appointed by the Governor.
West Florida Regional Planning Pleasure
of the
Council, Region One
Governor
West Orange Airport Authority
West Orange Airport Authority
West Orange Airport Authority
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Withlacoochee Regional
Planning Council, Region Five
Yes
Vacant
*SC= Senate Confirmation
State of Florida
Gubernatorial Appointments Office
Contact:
850 / 717-9243
850 / 921-0733 (fax)
[email protected]
The Appointments Office supports the Governor in meeting his major obligation to appoint qualified, representative and appropriate people to a large
number of important leadership roles throughout the State.
Board and Commission Vacancies
AIA Florida Appointment Spreadsheet
Action:
Fillout the application at the following link:
Gubernatorial Appointments Questionnaire
Example of application:
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. The
questionnaire MUST BE COMPLETED IN FULL. Answer "none" or "not applicable" where appropriate.
1- General
Title *
First Name *
Middle / Maiden
Last Name *
Email Address
Cell Phone
Race *
Gender *
Fax #
Do you have a disability? If “Yes” list *
Addresses
Specify the preferred mailing address *
Business
Residential
Yes
No
2- Residence
Street *
City *
State *
County *
Zip / Postal Code *
Phone Number
3- Business
Office #
Street
City
State
Zip / Postal Code
Phone Number
4- A. List all your places of residence for the last ten (10) years.
Address
City & State
Start Date
End Date
Action
Insert
B. List all your former and current residences outside of Florida that you have maintained at any time during adulthood.
Address
City & State
Start Date
End Date
Action
Insert
5- Date of Birth *
Place of Birth *
6- Driver License Number
Issuing State
7- Social Security Number *
8- Have you ever used or been known by any other legal name? If “Yes” list *
Yes
9- A. Are you a United States citizen? If “No” list
No
Yes
No
B. If you are a naturalized citizen, date of naturalization
10- Since what year have you been a continuous resident of Florida?
11- Vote
Are you a registered Florida voter? If “Yes” list *
Yes
County of registration
No
Current party affiliation
12- A. High School
Year Graduated
B. List all postsecondary educational institutions attended
Name & Location
Start Date
End Date
Certificates / Degrees
Action
Received
Insert
13- Are you or have you ever been a member of the armed forces of the United States? If “Yes” list *
A. Date of service
Yes
No
B. Branch or component
C. Date & Type of Discharge
14- Concerning your current employer and for all of your employment during the last ten years, list your employer’s name, business address, type of business,
occupation or job title, and period(s) of employment *
Employer's Name & Address Type of Business
Occupation / Job Title
Start Date
End Date
Action
Insert
15- Have you ever been employed by any state, district, or local governmental agency in Florida? If “Yes” list *
Yes
No
Position
Employing Agency
Start Date
End Date
Action
Insert
16- A. State your experiences and interests or elements of your personal
B. Have you received any degree(s), professional certification(s), or
history that qualify you for this appointment
designations(s) related to the subject matter of this appointment? If “Yes” list
Yes
No
C. Have you received any awards or recognitions relating to the subject matter
D. Identify all association memberships and association offices held by you that
of this appointment? If “Yes” list
relate to this appointment
Yes
No
17- Do you currently hold an office or position (appointive, civil service, or other) with the federal or any foreign government? If “Yes” list *
Yes
No
18- Have you previously been appointed to any office that required confirmation by the Florida Senate? If “Yes” list
Yes
No
Title of Office
Term of Appointment
Confirmation Results
Action
Insert
19- A. Have you ever been elected or appointed to any public office in this state? If “Yes” list *
Office Title
Date of Election or
Term of Office
Appointment
Yes
No
Level of Government (city, county, Action
district, state, federal)
Insert
B. If your service was on an appointed board(s), committee(s), 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(s) for your
absence(s)
Meetings Attended
Meetings Missed
Reason for Absence
Action
Insert
20- Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, regulation, or ordinance? (Exclude traffic
violations for which a fine or civil penalty of $150 or less was paid.) If “Yes” list *
Yes
No
Date
Place
Nature
Disposition
Action
Insert
21- Has probable cause ever been found that you were in violation of the Code of Ethics for Public Officers and Employees, Part III, Chapter 112, F.S.? If “Yes”
list *
Yes
Date
No
Nature of Violation
Disposition
Action
Insert
22- Have you ever been suspended from any office by the Governor of the State of Florida? If “Yes” list *
Yes
Title of Office
Reason for Suspension
Date of Suspension
Result
23- Have you ever been refused a fidelity, surety, performance, or other bond? If “Yes” list *
Yes
No
No
24- Have you held or do you hold an occupational or professional license or certificate in the State of Florida? *
Yes
No
If “Yes”, provide the title and number, original issue date, and issuing authority. If any disciplinary action (fine, probation, suspension,
revocation, disbarment) has ever been taken against you by the issuing authority, state the type and date of the action taken
License / Certificate Title & Number Original Issue Date
Issuing Authority
Disciplinary Action
Action
Insert
25- Have you ever been a registered lobbyist or have you lobbied at any level of government at any time during the past five (5) years? *
A. Did you receive any compensation other than reimbursement for expenses?
Yes
Yes
No
No
B. Name of agency or entity you lobbied and the principal(s) you represented
Agency Lobbies
Principal Represented
26- If required by law or administrative rule, will you file financial disclosure statements?
Yes
Action
No
27- A. Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or other 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? If “Yes”
list *
Yes
No
Name of Business
Your Relationship to Business
Business Relationship to Agency Action
Insert
B. Have members of your immediate family (spouse, child, parents(s), siblings(s)), or businesses of which members of your immediate family have been owners,
officers, or employees, held any contractual or other 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? If “Yes” list *
Yes
No
Name of Business
Family Member's Relationship to You
Family Member's
Business Relationship to Agency Action
Relationship to Business
Insert
28- List three persons who have known you well within the past five (5) years. Include a current, complete address and telephone number. Exclude your relatives
and members of the Florida Senate.
Name
Mailing Address
Zip Code
Phone Number
Action
Insert
29- Name any business, professional, occupational, civic, or fraternal organizations(s) of which you are now a member, or of which you have been a member
during the past five (5) years, the organization address(es), and date(s) of your membership(s)
Name
Mailing Address
Office(s) Held & Term
Date of Membership
Action
Insert
30- 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? If “Yes”
list *
Yes
No
31- Are you now, or in the past three years have you been, a member of any club or organization that, to your knowledge, in practice or policy, restricts
membership or restricted membership during the time that you belonged on the basis of race, religion, national origin, or gender? If so, detail the name and
nature of the club(s) or organization(s), relevant policies and practices, and state whether you intend to continue as a member if you appointed by the Governor?
If “Yes” list
Yes
No
You can apply for up to 5 board seats per application.
Functional Category *
All
Board Name *
Board Description
Seat Qualification *
Are you applying for reappointment ?
For Category
For Board
Yes
No
Add
For Seat
Functional Category
Board Name
Seats
Seat Qualification
Reappointment
Action
Resume
Please upload your
resume /CV
Only [doc, docx, pdf] files
I understand that any appointment tendered to me will be contingent upon the results of a background investigation, and I am aware that
withholding information or making false statements on this application may be the basis for non-appointment by the Executive Office of the
Governor. I agree to these conditions, and under the penalties of perjury I declare that I have read the foregoing application and that the facts stated
in it are true, correct, and complete to the best of my knowledge and belief. *
As a general matter, applications for all positions within state Government are public records, which may be viewed by anyone upon request.
However, there are some exemptions from the public records law for identifying information relating to past and present law enforcement officers
and their families, victims of certain crimes, etc. If you believe an exemption from the public records law applies to portions of your application,
please check this box.
First Name *
Last Name *
If you need additional guidance as to the applicability of any public records law exemption to your situation, please contact the Office of the Attorney
General.
Office of the Attorney General
PL-01, The Capitol
Tallahassee, Florida 32399
(850) 245-0158
Preview
Follow-up with a written letter to the following
Mailing Address
Governor’s Appointments Office
The Capitol Building
Lower Level, Suite LL-09
Tallahassee FL 32399-0001
Recent Appointments
QUESTIONNAIRE
for
GUBERNATORIAL APPOINTMENTS
Please Return To:
400 South Monroe Street
Capitol Building, Suite LL-09
Tallahassee, Florida 32399
FOR THE GOVERNOR’S APPOINTMENTS OFFICE
The information from this page has been requested and will be used exclusively by the GOVERNOR’S OFFICE.
Please type or use black ink.
1.
Board of Interest: ___________________________________________________________________________
2. Seat of Interest: ___________________________________________________________________________
3.
Current Employer and Occupation: ____________________________________________________
4.
Are you applying for reappointment:
5.
Yes 
*Do you have a disability? Yes 
No 
you for this appointment, if applicable.
6. *Sex:
Male 
7. *Race:
White
Hispanic-American
African-American
No 
If “Yes”, please describe your disability that would qualify
Female 



Native-American/Alaskan Native
Asian/Pacific Islander


8. Are you now, or in the past three years have you been, a member of any club or organization that, to your
knowledge, in practice or policy, restricts membership or restricted membership during the time that you
belonged on the basis of race, religion, national origin, or gender? If so, detail the name and nature of the
club(s) or organization(s), relevant policies and practices, and state whether you intend to continue as a member
if you appointed by the Governor. If yes, please describe. Yes
No
Email address____________________________________________________________________________
Cellular Telephone Number_________________________________________________________________
__________________________________
Applicant’s Name, including name
commonly used (Please print)
*
This information will be used to provide demographic statistics and is not requested for the purpose of discriminating on any basis.
Revised 11/2011
1
QUESTIONNAIRE FOR GUBERNATORIAL APPOINTMENTS
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. The questionnaire MUST BE COMPLETED IN FULL. Answer “none” or “not
applicable” where appropriate. Please type or print in black ink.
_______________________________
Date Completed
1.
Name: ______________________________________________________________________________________________
MR./MRS./MS./DR.
2.
LAST
FIRST
MIDDLE/MAIDEN
Business Address: _____________________________________________________________________________________
STREET
OFFICE #
CITY
____________________________________________________________________________________________________
POST OFFICE BOX
3.
STATE
ZIP CODE
AREA CODE/PHONE NUMBER
Residence Address: ____________________________________________________________________________________
STREET
CITY
COUNTY
____________________________________________________________________________________________________
POST OFFICE BOX
Specify the preferred mailing address:
STATE
ZIP CODE
Business

Residence
AREA CODE/PHONE NUMBER

Fax # ___________________
(optional )
4.
A.
List all your places of residence for the last ten (10) years.
ADDRESS
CITY & STATE
FROM
TO
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B.
List all your former and current residences outside of Florida that you have maintained at any time during adulthood.
ADDRESS
CITY & STATE
FROM
TO
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
5.
Date of Birth: _______________________________
6.
Social Security Number: _______________________________________________________________________________
7.
Driver License Number: _________________________________________ Issuing State: _________________________
Revised 11/2011
Place of Birth: _________________________________________
2
8.
Have you ever used or been known by any other legal name?
Yes

No

If “Yes,” list and explain.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
9.
Are you a United States citizen?
Yes 
No 
If “No” explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If you are a naturalized citizen, date of naturalization: _________________________________________________________
10. Since what year have you been a continuous resident of Florida? ________________________________________________
11. Are you a registered Florida voter?
A.
Yes 
No 
County of registration: _______________________
B.
If “Yes” list:
Current party affiliation: ____________________________
12. Education
A.
High School: ____________________________________________________
Year Graduated: ______________
(NAME AND LOCATION)
B.
List all postsecondary educational institutions attended:
NAME & LOCATION
DATES ATTENDED
CERTIFICATES/DEGREES RECEIVED
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
13. Are you or have you ever been a member of the armed forces of the United States? Yes 
No 
If “Yes” list:
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, regulation, or
ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less was paid.) If “Yes” give details:
DATE
PLACE
NATURE
DISPOSITION
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Revised 11/2011
3
15. Concerning your current employer and for all of your employment during the last ten years, list your employer’s name,
business address, type of business, occupation or job title, and period(s) of employment.
EMPLOYER’S NAME & ADDRESS
TYPE OF BUSINESS
OCCUPATION/JOB TITLE
PERIOD OF EMPLOYMENT
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
16. Have you ever been employed by any state, district, or local governmental agency in Florida?
Yes 
If “Yes”, identify the position(s), the name(s) of the employing agency, and the period(s) of employment:
POSITION
EMPLOYING AGENCY
No 
PERIOD OF EMPLOYMENT
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
17. A.
State your experiences and interests or elements of your personal history that qualify you for this appointment.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B.
Have you received any degree(s), professional certification(s), or designations(s) related to the subject matter of this
appointment? Yes 
No 
If “Yes”, list:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
C.
If
Have you received any awards or recognitions relating to the subject matter of this appointment? Yes 
“Yes”, list:
No 
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Revised 11/2011
4
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 
No 
If “Yes”, list:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
19. A.
Have you ever been elected or appointed to any public office in this state? Yes  No  If “Yes”, state the
office title, date of election or appointment, term of office, and level of government (city, county, district, state,
federal):
OFFICE TITLE
DATE OF ELECTION OR APPOINTMENT
TERM OF OFFICE
LEVEL OF GOVERNMENT
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B.
(1)
If your service was on an appointed board(s), committee(s), or council(s):
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(s) for your absence(s).
MEETINGS ATTENDED
MEETINGS MISSED
REASON FOR ABSENCE
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
20. Has probable cause ever been found that you were in violation of the Code of Ethics for Public Officers and Employees, Part
III, Chapter 112, F.S.? Yes

No 
If “Yes”, give details:
DATE
NATURE OF VIOLATION
DISPOSITION
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
21. Have you ever been suspended from any office by the Governor of the State of Florida? Yes 
No  If “Yes”, list:
A.
Title of office: ____________________________
C.
Reason for suspension: _______________________________
B.
Date of suspension: ________________________
D.
Result: Reinstated 
Revised 11/2011
5
Removed 
Resigned 
22. Have you previously been appointed to any office that required confirmation by the Florida Senate?
If “Yes”, list:
Yes

No 
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 
No 
If “Yes”, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
24. Have you held or do you hold an occupational or professional license or certificate in the State of Florida? Yes  No 
If “Yes”, provide the title and number, original issue date, and issuing authority. If any disciplinary action (fine, probation,
suspension, revocation, disbarment) has ever been taken against you by the issuing authority, state the type and date of the
action taken:
LICENSE/CERTIFICATE
TITLE & NUMBER
ORIGINAL
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 other 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 
No 
If “Yes”, explain:
NAME OF BUSINESS
YOUR RELATIONSHIP TO BUSINESS
BUSINESS’ RELATIONSHIP TO AGENCY
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
B.
Have members of your immediate family (spouse, child, parents(s), siblings(s)), or businesses of which members of
your immediate family have been owners, officers, or employees, held any contractual or other 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 
No 
If “Yes”, explain:
NAME OF BUSINESS
FAMILY MEMBER’S
FAMILY MEMBER’S
BUSINESS’ RELATIONSHIP
RELATIONSHIP TO YOU
RELATIONSHIP TO BUSINESS
TO AGENCY
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
26. Have you ever been a registered lobbyist or have you lobbied at any level of government at any time during the past five (5)
years? Yes  No 
A.
Did you receive any compensation other than reimbursement for expenses? Yes 
B.
Name of agency or entity you lobbied and the principal(s) you represented:
AGENCY LOBBIED
No 
PRINCIPAL REPRESENTED
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Revised 11/2011
6
27. List three persons who have known you well within the past five (5) years. Include a current, complete address and
telephone number. Exclude your relatives and members of the Florida Senate.
NAME
MAILING ADDRESS
ZIP CODE
AREA CODE/PHONE NUMBER
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
28. Name any business, professional, occupational, civic, or fraternal organizations(s) of which you are now a member, or of
which you have been a member during the past five (5) years, the organization address(es), and date(s) of your
membership(s).
NAME
MAILING ADDRESS
OFFICE(S) HELD & TERM
DATE(S) OF MEMBERSHIP
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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  No  If “Yes”, explain:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
30. If required by law or administrative rule, will you file financial disclosure statements? Yes 
Revised 11/2011
7
No 
CERTIFICATION
STATE OF FLORIDA, COUNTY OF
Before me, the undersigned Notary Public of Florida, personally appeared
_____________________________________, who, after being duty sworn, say: (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 the United States and of
the State of Florida.
___________________________________________
Signature of Applicant-Affiant
Sworn to and subscribed before me
this____________ day of ______________, 20___.
___________________________________________
Signature of Notary Public-State of Florida
___________________________________________
(Print, Type, or Stamp Commissioned Name of Notary Public)
My commission expires: ________________________
Personally Known

OR
Produced Identification

Type of Identification Produced _______________________________________________
(seal)
Revised 11/2011
8
MEMORANDUM
AS A GENERAL MATTER, APPLICATIONS FOR ALL POSITIONS WITHIN STATE
GOVERNMENT ARE PUBLIC RECORDS, WHICH MAY BE VIEWED BY ANYONE
UPON REQUEST. HOWEVER, THERE ARE SOME EXEMPIONS FROM THE
PUBLIC RECORDS LAW FOR IDENTIFYING INFORMATION RELATING TO PAST
AND PRESENT LAW ENFORCEMENT OFFICERS AND THEIR FAMILIES, VICTIMS
OF CERTAIN CRIMES, ETC…IF YOU BELIEVE AN EXEMPTION FROM THE PUBLIC
RECORDS LAW APPLIES TO YOUR SUBMISSION, PLEASE CHECK THIS BOX.
□
Yes, I assert that identifying information
provided in this application should be
excluded from inspection under Public
Records Law. Please indicate what
section of Florida Statutes provides this
in your particular situation.
__________________________________
IF YOU NEED ADDITIONAL GUIDANCE AS TO THE APPLICABILITY OF ANY
PUBLIC RECORDS LAW EXEMPTION TO YOUR SITUATION, PLEASE CONTACT
THE OFFICE OF THE ATTORNEY GENERAL.
The Office of the Attorney General
PL-01, The Capitol
Tallahassee, Florida 32399
(850) 245-0158
Revised 11/2011
9