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2. Name of Board or Boards for which you are applying:*
4. Name:*
6. Home Address:*
8. City:*
9. State:*
10. Zip:*
12. How long at this address?*
13. Telephone Number*
15. If less than two years, provide prior address:
17. Are you a citizen of the United States? *

    1. Yes
    2. No
19. Occupation: *
21. Employer:*
23. Do you own a business that operates within the City of Fort Pierce?*

    1. Yes
    2. No
25. If yes, list the address and nature of said business:
27. Do you now or in the future plan to do business with the City of Fort Pierce or the Fort Pierce Utilities Authority(FPUA)?*

    1. Yes
    2. No
29. If yes, in which organization and in what capacity?
31. Are you employed by a business that is located within the City of Fort Pierce?*

    1. Yes
    2. No
33. If yes, state the business and location:
35. Do you have special training or knowledge in the area of:
37. Engineering:*

    1. Yes
    2. No
38. Architecture:*

    1. Yes
    2. No
39. Real Estate Brokering:*

    1. Yes
    2. No
40. Finanace/Accounting:

    1. Yes
    2. No
42. Contracting:*

    1. Yes
    2. No
43. Land Development:*

    1. Yes
    2. No
44. Utilities:

    1. Yes
    2. No
45. Management:*

    1. Yes
    2. No
47. Describe your professional background and what expertise you will bring to this Board. (Attach your resume or other applicable information below if desired) *
49. Are you currently a member of a Commission-appointed board/committee?*

    1. Yes
    2. No
51. If yes, please specify:
53. Have you ever been convicted of a felony?*

    1. Yes
    2. No
55. If yes, what was the nature of the crime(s) you were convicted of:
57. If appointed, are you willing to attend a training session which could last several hours?*

    1. Yes
    2. No
59. Referred by:*
60. Applicant Email Address:*
62. Date:*
63. Applicant’s Signature:*

65. APPLICATIONS EXPIRE 6 MONTHS FROM THE DATE OF SUBMISSION. PLEASE REAPPLY AS OFTEN AS DESIRED. 

    For additional information, please contact the City Clerk’s Office at 772.467.3065 or email lcox@cityoffortpierce.com. 

67. Upload Resume (Optional)
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69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field