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Questionnaire for County Appointments Instructions
 

Information from this questionnaire will be used by the Board of County Commissioners of Hillsborough County when considering appointments to advisory boards and councils. Please fill out all fields and follow the instructions at the bottom of this form or download the Questionaire for County Appoinments Application ( PDF, 58KB ) .

* To print out this form, click on the "Printer-Friendly" link above, then select "Landscape Format" in your printer settings.
 
BOARD OF INTEREST:
1. Name:
First
Middle
Last
2. Place of Employment:
Job Title:
3. Business Address:
Street
PO Box/Suite
City
State
Zip
Phone Number
4. Residence Address:
Street
PO Box/Suite
City
State
Zip
Phone Number
Please Note: The following information will be used to satisfy Equal Opportunity reporting requirements.
5. Sex:
Male Female
6. Race:
White, non-Hispanic Hispanic Black
Asian / Pacific Islander American Indian / Alaskan Native
Please Note: Response to the following question is optional.
7. Are you a person with a disability? Yes   No
If yes, please explain the nature of your disability:
8. Date of birth: Place of birth:
9. Have you ever been convicted of any felony or misdemeanor offense? Yes No
If yes, please explain (You may omit minor traffic violations and any offense committed as a minor).
10. Are you a registered voter in Hillsborough County?
(All nominees must be registered voters in Hillsborough County.)
Yes No
   
11. Are you currently serving in another position appointed by the Board of County Commissioners? Please note that members can only serve on one board/council/commission/authority at a time (this limitation only applies to those boards and councils whose members are appointed by the full Board of County Commissioners.)
Yes No
If yes, list name of board
12. Continuous Resident of Hillsborough County since: .
13. Education:  
A. High School: Year Graduated:
B. List all post secondary educational institutions attended:
NAME & LOCATION
DATES ATTENDED
DEGREE(S) RECEIVED
14. Do you have any relatives working for Hillsborough County?
Yes No
    If yes, list their name, relationship and office:
 
15. Have you ever held a professional or business license or certificate?
Yes No
If yes, please list below. If any disciplinary action has been taken, please indicate the date and type of action taken.
Please include the number of your license or certificate.
LICENSE/CERTIFICATE
/BAR N o.
DATE ISSUED
ISSUING AUTHORITY
DISCIPLINARY ACTION
16. State your experience and interests or elements of your personal history that qualify you for appointment:
 
17. If you are appointed, do you know of any reason whatsoever why you will not be able to attend regularly scheduled meetings or otherwise fulfill the duties of the office to which you have been appointed? . Yes No
If yes, please explain:
18. To your knowledge, have you, members of your immediate family, or business of which you or members if your immediate family have been an owner, officer or employee, held any contractual or other dealings during the last three (3) years with any Hillsborough County government agency, including the agency to which you seek appointment? . Yes No
If yes, please list below.  
BUSINESS
YOUR RELATIONSHIP TO BUSINESS
BUSINESS RELATIONSHIP TO AGENCY
19. Please list three persons who have known you well within the past five (5) years. Include a current and complete address, phone number and the capacity in which they have known you. Please list only those persons who have given their consent to be used as a reference/
NAME
ADDRESS
PHONE NUMBER
CAPACITY
20. Name any business, professional, civic or fraternal organizations of which you are a member, and the dates of your memberships.
ORGANIZATIONS
DATE OF MEMBERSHIP
21. Do you or your firm / business present variances or special use permits before the Land Use Hearing Officer?
      Yes No
22. If yes, how often?


Note: If you are applying for one of the following boards, a criminal background check is required. Any appointment to one of these boards or as a hearing officer is contingent upon the results of the criminal background check. You must complete the authorization form on the next page and return with this questionnaire:

  • Child Care Facilities Advisory Board
  • Child Care Licensing Hearing Officers
  • Children's Services Advisorty Board
  • Family Day Care Home Advisory Board
  • Parks, Recreation & Conservation Board
  • Public Library Board
  • School Readiness Coalition
 

AS A MEMBER OF THE FOLLOWING BOARDS, YOU WILL BE REQUIRED AS A “LOCAL OFFICER” TO FILE A FINANCIAL DISCLOSURE FORM WITHIN 30 DAYS OF APPOINTMENT AS WELL AS ANNUALLY THEREAFTER.
  • Arts Council
  • Building Board of Adjustment
  • Appeals & Examiners
  • Code Enforcement Board
  • Code Enforcement Special Magistrates
  • Electrical Board of Adjustment
  • Appeals & Examiners
  • Gas Board of Adjustment
  • Appeals & Examiners
  • Hillsborough Area Regional Transit Authority
  • Hospital Authority
  • Human Relations Board
  • Industrial Development Authority
  • Land Use Appeals Board
  • Mechanical Board of Adjustment
  • Appeals & Examiners
  • Nuisance Abatement Board
  • Planning Commission
  • Plumbing Board of Adjustment
  • Appeals & Examiners
  • Tampa Sports Authority.
 
INSTRUCTIONS FOR SUBMITTAL:
To submit the completed form, deliver it to:
Boards and Councils Coordinator
Board of County Commissioners
601 East Kennedy Boulevard, 2 nd Floor
Tampa, Florida
Or mail the completed form to:
Boards and Councils Coordinator
P.O. Box 1110
County Center, 2 nd Floor
Tampa, Florida 33601-1110
For this form to be valid, please sign below.

 


    
PRINT NAME
SIGNATURE
DATE
 
 
=====================================================================
Background Investigation Disclosure and Authorization Form
By signing the release below, I hereby authorize Hillsborough County to contact any and all corporations, former employers, educational institutions, law enforcement agencies, city, state, county, and federal courts, and military services to release information about my background including, but not limited to, information about employment, education, driving record, criminal record and general public records history to Hillsborough County.

I understand that my appointment is subject to satisfactory completion of a background investigation including verification of information I supplied in my application for appointment.

I release from all liability all persons, companies, and schools supplying such information. I release Hillsborough County from and indemnify Hillsborough County against any liability whatsoever in connection with such background investigation report and the use of the results obtained in the appointment process.

I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I fully understand the terms of this release.
Name:
(Please print)
Other Name(s) Used:
Address:
City/State/Zip:
Date Received Degree (If Applicable):
University/School Degree Earned From:
Social Security #:
Driver's License Number & State:
 
 
Additional forms may be necessary under the Fair Credit Reporting Act.
=====================================================================
 
 
E-MAIL ADDRESS:
FAX NUMBER:
 
   
SIGNATURE
DATE
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Hillsborough County is an Equal Opportunity/Affirmative Action Employer

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