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NEW--Application for Board/Committee Membership

  1. City of Cocoa Application for Board/Committee Membership
    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. (Please Print)
  3. *The information being requested is necessary in order to conduct a background check. Information will be used for those purposes only.
  4. Various City Boards/Committees Available*
    (Please Check All Those That Interest You)
  5. Eligibility
  6. Have you been a City of Cocoa resident for at least 6 months?*
  7. Do you own property or a business in Cocoa?*
  8. If yes, please list all addresses you own in the City of Cocoa:

  9. Are you registered to vote in Brevard County, Florida?*
  10. 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.*
  11. If yes, have your civil rights been restored?
  12. Do you consent to a standard criminal background check?*
  13. Miscellaneous Information
  14. Do you currently serve on any other City of Cocoa board?*
  15. Are you related to a City of Cocoa Councilmember by blood, adoption, or marriage?*
  16. 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.*
  17. Interests and Experience
  18. State Reporting Requirements
    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:
  19. Race*
  20. Gender*
  21. Disability
  22. Applicant Certification
    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)
  23. 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.
  24. All meetings are subject to change in dates and/or may be canceled with the approval of the City Manager (with the exception of the regular Council meetings), dependent upon whether there are items or cases to be considered. Other meetings of boards not listed above are held on an infrequent basis to which there is no standard or specified monthly date. (Please refer to the preceding "Description of Boards and Committees".) The three pension boards generally meet quarterly, and meetings may be held more often, depending on necessity. The Drug Related Public Nuisance Board holds meetings coinciding with the Code Enforcement Board; however, it meets infrequently on an as needed basis. THIS INFORMATION IS PUBLISHED BY THE CITY CLERK'S OFFICE IN AN EFFORT TO BETTER INFORM CITIZENS ABOUT THEIR CITY GOVERNMENT.
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  26. This field is not part of the form submission.