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CareerSource Palm Beach County, Inc. Application

2. The information provided on this form will be used in considering your appointment. Please COMPLETE SECTION II IN FULL. Answer “none” or “not applicable” where appropriate. Please attach a biography or résumé to this form.

4. Section I: Board Name: CAREERSOURCE PALM BEACH COUNTY, INC.

6. X Not Advisory

7. X New Appointment

9. Section II: (Applicant):

11. APPLICANT, UNLESS EXEMPTED, MUST BE A COUNTY RESIDENT

13. Last Name:*

14. First Name:*

15. Middle Name:

17. Occupation/Affiliation:*

19. Type of Employment*

    1. Owner

    1. Employee

    1. Officer

21. Business Name:*

23. Business Address:*

25. City:*

26. State:*

27. Zip Code:*

29. Residence Address:*

31. City:*

32. State:*

33. Zip:*

35. Home Phone Number:

36. Business Phone Number:

38. Cell Phone Number:*

39. Fax:

41. Email Address:*

43. Mailing Address Preference:*

    1. Business

    1. Residence

45. Have you ever been convicted of a felony:*

    1. Yes

    1. No

47. If Yes, state the court, nature of offense, disposition of case and date:

49. Gender:

    1. Male
    2. Female

51. Minority Indentification Code:

    1. Native-American
    2. Hispanic-American

    1. Asian-American

    1. African-American

    1. Causcasian

53. CONTRACTUAL RELATIONSHIPS: Pursuant to Article XIII, Sec. 2-443 of the Palm Beach County Code of Ethics, advisory board members are prohibited from entering into any contract or other transaction for goods or services with Palm Beach County. Exceptions to this prohibition include awards made under sealed competitive bids, certain emergency and sole source purchases, and transactions that do not exceed $500 per year in aggregate. These exemptions are described in the Code. This prohibition does not apply when the advisory board member’s board provides no regulation, oversight, management, or policy-setting recommendations regarding the subject contract or transaction and the contract or transaction is disclosed at a public meeting of the Board of County Commissioners. To determine compliance with this provision, it is necessary that you, as a board member applicant, identify all contractual relationships between Palm Beach County government and you as an individual, directly or indirectly, or your employer or business. This information should be provided in the space below. If there are no contracts or transactions to report, please verify that none exist. Staff will review this information and determine if you are eligible to serve or if you may be eligible for an exception or waiver pursuant to the code.

55. Contract/Transaction No.

    Example: (R#XX-XX/PO XX)

56. Department/Division

    Example: Parks & Recreation

57. Description of Services

    Example: General Maintenance

58. Term

    10/01/00-09/30/2100

60. Contract/Transaction No.

61. Department/Division

62. Description of Services

63. Term

65. Contract/Transaction No.

66. Department/Division

67. Description of Services

68. Term

70. Or Select:

    1. NONE

    1. NOT APPLICABLE/ (Governmental Entity)

72. If appointed, all board members are required to read and complete training on Article XIII, the Palm Beach County Code of Ethics, and read the State Guide to the Sunshine Amendment. Article XIII, and the training requirement can be found on the web at: http://www.palmbeachcountyethics.com/training.htm Ethics training is on-going, and pursuant to PPM CW-P-79 is required before appointment, and upon reappointment.

74. Please attach a biography or résumé to this form

Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit Submit and Print

* indicates a required field