Application for Chief Financial Officer Board and Commission Appointments

Complete this form in its entirety and return to the Florida Department of Financial Services (DFS). This form may be completed online and submitted electronically. This form may be completed online, or printed and mailed to: Florida Department of Financial Services Chief Financial Officer Jimmy Patronis Attn: Internal Affairs 200 East Gaines Street Tallahassee, FL 32399-0301 Contact DFS at (850) 413-4900 with any questions or concerns.

Board(s) of Interest

Personal Information

Name

First, Middle, Last

Have you ever been known by any other name?

Yes

Spouse's Name

Email Address

Provide the email address you prefer correspondence, regarding this application, be sent:

Gender

Male

Female

Describe yourself within one or more of the categories below. This information is requested pursuant to Section 760.80, Florida Statutes.

Access the Statute online : https://www.flsenate.gov/Laws/Statutes/2019/760.80

Birth Date

mm/dd/yyyy

Birthplace

City, State, Zip

As of what date have you been a continuous resident of Florida?

mm/dd/yyyy

Are you a U.S. Citizen?

Yes

Naturalized Citizen

Are you or have you ever been a member of the armed forces of the United States?

Yes

Contact Information

Residential Street Address

Residential City, State, Zip

Residential PO Box

Residential Phone

Mobile

Business Street Address

Business City, State, Zip

Business PO Box

Business Phone

Business Email

Provide the requested information for your current and all employers within the last 5 years:

Employer 1

Employer Address

Type of Business

Occupation/Job Title

Dates of Employment

Employer 2

Employer Address

Type of Business

Occupation/Job Title

Dates of Employment

Employer 3

Employer Address

Type of Business

Occupation/Job Title

Dates of Employment

Employer 4

Employer Address

Type of Business

Occupation/Job Title

Dates of Employment

Employer 5

Employer Address

Type of Business

Occupation/Job Title

Dates of Employment

Education

High School

Name, City, State

Postsecondary Institutions

Name & Location, Dates Attended, Certificate/Degree Earned

Special Qualifications

List any of your special qualifications you consider relevant to being appointed to a board, commission, council, or committee, including any type of licensure or certification you hold.

Type/Name of License/Certificate, Number, Granting Agency, Date Granted

Names of civic, professional, or political organizations to which you belong.

Name of Organization, Office(s) Held, Membership Start Date

Give any additional information you consider relevant to your appointment to a board, commission, council, or committee.

Ethical Disclosure

If required by law or administrative rule, will you file financial disclosure statements?

Yes

Have you been a registered lobbyist, or have you lobbied, at any level of government at any time during the past four years?

Yes

Have you or any business with which you are or have been affiliated as an owner, officer, or employee ever held any contractual dealings during the last four years with any state, district, or local governmental agency in Florida?

Yes

Have members of your immediate family [spouse, child, parent(s), sibling(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 years with any state, district, or local governmental agency in Florida?

Yes

Has probable cause ever been found that you were in violation of Part III, Chapter 12, Florida Statutes, or the Code of Ethics for Public Officers and Employees?

Yes

Have you ever been suspended from any office by the Governor of the State of Florida?

Yes

Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law or ordinance? (Exclude traffic violations for which a fine of $150 or less was paid.)

Yes

Have you ever been refused a fidelity, surety, performance, or other bond?

Yes

Do you know of any reason why you would not be able to attend fully to the duties of the office or position to which you may be appointed?

Yes

Public Service

Are you currently or have you ever been elected to any public office in Florida?

Yes

Have you ever been appointed to any public office in Florida?

Yes

Have you previously been appointed to any office that required confirmation by the Florida Senate?

Yes

Have you ever been employed by any state, district, or local governmental agency in Florida?

Yes

References

List three persons who have known you well within the past five years and provide the requested information on each person. Exclude relatives.

Reference 1 - Name

Reference 1 - Address

Reference 1 - Phone

Reference 2 - Name

Reference 2 - Address

Reference 2 - Phone

Reference 3 - Name

Reference 3 - Address

Reference 3 - Phone

Do you certify that the above statements are true?

Yes

Do you authorize DFS to verify the information given?

Yes

If selected for appointment, do you agree to voluntarily submit your SSN, and your Driver’s License Number.

Yes

Date

mm/dd/yyyy

Applicant's Signature

Send me a copy of my responses

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