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Application for Board/Committee Membership

  1. City Code requires prospective and existing board members to fill out an application, consent to a standard criminal background check*, be duly registered to vote in Brevard County, and be a resident or an owner of real property in the City of Cocoa. City Code also prohibits a person from serving on a City Board or Committee if that person has been convicted of a felony, unless their civil rights have been restored.

  2. The information being requested is necessary in order to conduct a background check. Information will be used for those purposes only.

  3. Various City Boards/Committees Available*

    (Please Check All Those That Interest You)

  4. Have you been a City of Cocoa resident for at least 6 months?*

  5. Do you own property or a business in Cocoa?*

  6. Are you registered to vote in Brevard County, Florida?*

  7. Have you ever been convicted or found guilty, regardless of adjudication, of a felony in any jurisdiction? Any plea of no contest shall be considered a conviction for purposes of this question.*

  8. If yes, have your civil rights been restored?

  9. Do you consent to a standard criminal background check?*

  10. Do you currently serve on any other City of Cocoa board?*

  11. Are you related to a City of Cocoa Councilmember by blood, adoption, or marriage?*

  12. Potential Conflict of Interest: Have you ever been engaged in the management of any business enterprise that has a financial interest with the City of Cocoa? Please provide details, such as the name of the enterprise, the nature of the business, and the positions you hold or have held.*

  13. Section 760.80, Florida Statutes, requires that the City annually submit a report to the Secretary of State disclosing race, gender, and physical disabilities of board and committee members. Please check the appropriate boxes:

  14. Race*

  15. Gender*

  16. Disability

  17. By filling this application with the City of Cocoa, I do hereby acknowledge the following: 1. This application, when completed and filed with the Office of the City Clerk, is a public record under Chapter 119, Florida Statutes, and is open to public inspection. 2. I am responsible for keeping the information on this form current and provide any changes or updates to the Office of the City Clerk. 3. I consent to filing a Statement of Financial Interests (Form 1) required if required for the board in which I am appointed to. 4. If appointed to a board/committee, I acknowledge that this is my obligation and duty to comply with the following: Code of Ethics for Public Offices (Florida Statutes, Chapter 112, Part III) Florida Sunshine Law (Florida Statutes, Chapter 286) http://www.flsenate.gov/Statutes.

  18. By typing in my full name above, I am acknowledging that the above information is accurate and I understand all of the information provided to me on this application and that I consent to all of the above.

  19. Leave This Blank:

  20. This field is not part of the form submission.