Submit Board Application
Step 1: Download and complete the
Appointment Questionnaire
Please note: This file must be downloaded to your local computer before being filled out. There is no save feature included with the online version of this form. Any information entered to the online version of the forms will be lost when downloaded. After the .pdf is downloaded and filled out it can be saved to your computer for upload and to retain a copy for your records.
Step 2: Attach completed Appointment Questionnaire
Note: Files must be 5 MB or less in size (Please contact the Appointments office if you have a larger file to upload)
Application Questionnaire
*
:
I have attached my Appointment Questionnaire and am ready to continue.
Step 3: Complete demographic and personal information**
Salutation
*
:
Select One...
Dr.
Mayor
Miss
Mr.
Ms.
Rabbi
Reverend
Senator
First Name
*
:
Middle Name:
Last Name
*
:
Email Address
*
:
Cell Phone Number (999) 999-9999
*
:
Fax Number (999) 999-9999:
Race
*
:
Select One...
African-American
Asian/Pacific Islander
Caucasian
Hispanic-American
Native-American/Alaskan Native
Unknown/Other
Gender
*
:
Select One...
Male
Female
Specify the preferred mailing address
*
:
Business
Residential
Residential Address
Address line 1
*
:
Address line 2:
City
*
:
State
*
:
Select One...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
OTHER
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
County
*
:
Zip
*
:
Home Phone Number (999) 999-9999:
Business Address
Address line 1:
Address line 2:
City:
State:
Select One...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
OTHER
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
County:
Zip:
Business Phone Number (999) 999-9999:
Personal Information
The Executive Office of the Governor (EOG), as authorized by section
119.071(5)(a)(2), Florida Statutes
, requests that you voluntarily submit your social security number (SSN). The EOG will use your SSN for purposes of conducting a background investigation relating to this application and may share the information with other agencies for the same purpose. If you provide your SSN, it will remain confidential and exempt and will not be disclosed to anyone outside of the EOG, except for the purposes mentioned in this disclosure or as otherwise provided by law. Your failure to provide your SSN may result in a delay in processing your application.
Date of Birth (mm/dd/yyyy)
*
:
Place of Birth
*
:
Social Security Number (999-99-9999)
*
:
Driver's License Number:
Issuing State:
Select One...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
OTHER
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Have you ever used or been known by any other legal name? If "Yes" list
*
:
Yes
No
If you are a naturalized citizen, date of naturalization:
Since what year have you been a continuous resident of Florida?:
Are you a United States Citizen? If "No" list countries:
Yes
No
Are you a registered Florida voter? If "Yes" list
*
:
Yes
No
County of registration:
Select One...
Alachua
Baker
Bay
Bradford
Brevard
Broward
Calhoun
Charlotte
Citrus
Clay
Collier
Columbia
DeSoto
Dixie
Duval
Escambia
Flagler
Franklin
Gadsden
Gilchrist
Glades
Gulf
Hamilton
Hardee
Hendry
Hernando
Highlands
Hillsborough
Holmes
Indian River
Jackson
Jefferson
Lafayette
Lake
Lee
Leon
Levy
Liberty
Madison
Manatee
Marion
Martin
Miami-Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Other
Palm Beach
Pasco
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington
Current party affiliation:
Select One...
Democrat
No Party Affiliation
Not Registered
Other
Republican
Step 4: Select board seat(s) to apply for
Functional Category (use to filter the boards below):
Select One...
Children Services
Colleges
DBPR
Disability Boards
Early Learning Coalitions
Economic Development
Education
Elected Official
Environmental
Family Care Councils
Health
Historical and Arts
Hospitals
Housing Authority
JNC
Law Enforcement
Miscellaneous
Regional Planning Councils
Transportation
Universities
Board Name:
*
Select One...
Acquisition and Restoration Council
Advisory Council for the Department of Health Website Information Clearinghouse on Developmental Disabilities
Alligator Point Water Resources Board
Alzheimer's Disease Advisory Committee
Apalachee Regional Planning Council, Region Two
Area Eight Family Care Council
Area Eleven Family Care Council
Area Fifteen Family Care Council
Area Five Family Care Council (Suncoast West Family Care Council)
Area Four Family Care Council
Area Fourteen Family Care Council
Area Nine Family Care Council
Area One Family Care Council
Area Seven Family Care Council
Area Six Family Care Council (Suncoast East Family Care Council)
Area Ten Family Care Council
Area Thirteen Family Care Council
Area Three Family Care Council
Area Twelve Family Care Council
Area Two Family Care Council
Baker County Development Commission
Barbers' Board
Big Cypress Basin Board
Biomedical Research Advisory Council
Board of Accountancy
Board of Acupuncture
Board of Architecture and Interior Design
Board of Athletic Training
Board of Auctioneers
Board of Chiropractic Medicine
Board of Clinical Laboratory Personnel
Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling
Board of Control for Southern Regional Education
Board of Cosmetology
Board of Dentistry
Board of Directors, Florida Center for Nursing
Board of Directors, Florida Education Fund
Board of Directors, Florida Fund for Minority Teachers, Inc.
Board of Employee Leasing Companies
Board of Funeral, Cemetery, and Consumer Services
Board of Governors of the State University System
Board of Hearing Aid Specialists
Board of Landscape Architecture
Board of Massage Therapy
Board of Medicine
Board of Nursing
Board of Nursing Home Administrators
Board of Occupational Therapy Practice
Board of Opticianry
Board of Optometry
Board of Orthotists and Prosthetists
Board of Osteopathic Medicine
Board of Pharmacy
Board of Physical Therapy Practice
Board of Pilot Commissioners
Board of Podiatric Medicine
Board of Professional Engineers
Board of Professional Geologists
Board of Psychology
Board of Respiratory Care
Board of Speech-Language Pathology and Audiology
Board of Trustees, Florida School for the Deaf and the Blind
Board of Trustees, Florida Virtual School
Board of Veterinary Medicine
Boating Advisory Council
Bradford County Development Authority
Brevard County Housing Authority
Broward County Housing Authority
Cape Canaveral Hospital District, Brevard County
CareerSource Florida Board of Directors
Central Florida Regional Planning Council, Region Seven
Children's Board of Hillsborough County
Children's Services Council of Broward County
Children's Services Council of Leon County
Children's Services Council of Okeechobee County
Children's Services Council of Palm Beach County
Children's Services Council of Saint Lucie County
Children's Trust Governing Board of Miami-Dade County
Chipola College District Board of Trustees
Citrus County Hospital Board
Clay County Development Authority
Clay County Utility Authority
College of Central Florida District Board of Trustees
Collier County Housing Authority
Columbia County Housing Authority
Commercial Motor Vehicle Review Board
Commission for the Transportation Disadvantaged
Commission on Mental Health and Substance Use Disorder
Construction Industry Licensing Board
Continuing Care Advisory Council
Council for Early Grade Success
Council on Homelessness
Criminal and Juvenile Justice Information Systems Council
Daytona State College District Board of Trustees
DeSoto County Hospital Board
Diabetes Advisory Council
District Medical Examiners
E911 Board
Early Learning Coalition of Brevard County
Early Learning Coalition of Broward County
Early Learning Coalition of Duval, Inc.
Early Learning Coalition of Escambia County
Early Learning Coalition of Indian River, Martin and Okeechobee Counties, Inc.
Early Learning Coalition of Northwest Florida
Early Learning Coalition of Osceola County
Early Learning Coalition of Palm Beach County, Inc.
Early Learning Coalition of Pasco and Hernando Counties, Inc.
Early Learning Coalition of Polk County
Early Learning Coalition of Sarasota County
Early Learning Coalition of Seminole County
Early Learning Coalition of Southwest Florida
Early Learning Coalition of St. Lucie County, Inc.
Early Learning Coalition of the Big Bend Region, Inc.
Early Learning Coalition of the Emerald Coast (Okaloosa and Walton Counties)
Early Learning Coalition of the Nature Coast (Dixie, Gilchrist, Levy, Citrus, and Sumter Counties)
East Central Florida Regional Planning Council, Region Six
Eastern Florida State College District Board of Trustees
Eastpoint Water and Sewer District
Eighteenth Circuit Judicial Nominating Commission
Eighth Circuit Judicial Nominating Commission
Electrical Contractors Licensing Board
Eleventh Circuit Judicial Nominating Commission
Environmental Regulation Commission
Escambia Children's Trust
Fifteenth Circuit Judicial Nominating Commission
Fifth District Court of Appeal Judicial Nominating Commission
First Circuit Judicial Nominating Commission
First District Court of Appeal Judicial Nominating Commission
Flagler County Housing Authority
Florida Agricultural and Mechanical University Board of Trustees
Florida Athletic Commission
Florida Building Code Administrators and Inspectors Board
Florida Building Commission
Florida Cancer Control and Research Advisory Council
Florida Center for Brain Tumor Research Scientific Advisory Council
Florida Children and Youth Cabinet Direct-Support Organization
Florida Citrus Commission
Florida Commission on Community Service (Volunteer Florida)
Florida Commission on Human Relations
Florida Commission on Offender Review
Florida Commission on the Status of Women
Florida Communities Trust
Florida Coordinating Council for the Deaf and Hard of Hearing
Florida Council on Arts and Culture
Florida Cybersecurity Advisory Council
Florida Developmental Disabilities Council
Florida Elections Commission
Florida Endowment Foundation for Vocational Rehabilitation (Able Trust)
Florida Faith-Based and Community-Based Advisory Council
Florida Fish and Wildlife Conservation Commission
Florida Gaming Control Commission
Florida Governor's Council on Indian Affairs, Inc.
Florida Greenways and Trails Council
Florida Healthy Kids Corporation Board of Directors
Florida Historical Commission
Florida Humanities Council
Florida Industrial and Phosphate Research Institute
Florida Inland Navigation District
Florida Interagency Coordinating Council for Infants and Toddlers
Florida International University Board of Trustees
Florida Martin Luther King, Jr., Institute for Nonviolence
Florida National Guard, General Officers
Florida Real Estate Appraisal Board
Florida Real Estate Commission
Florida Rehabilitation Council
Florida School for Competitive Academics Board of Trustees
Florida Southwestern State College District Board of Trustees
Florida Sports Foundation Board of Directors
Florida Transportation Commission
Florida Trauma System Advisory Council
Florida Violent Crime and Drug Control Council
Fourteenth Circuit Judicial Nominating Commission
Gainesville Regional Utilities Authority
Gainesville-Alachua County Regional Airport Authority
Governor's Mansion Commission
Governor's Panel on Excellence in Long-Term Care
Gubernatorial Fellows Board of Directors
Gulf Coast State College District Board of Trustees
Halifax Health Board of Commissioners
Hamilton County Development Authority Board of Supervisors
Hamilton County Memorial Hospital Board
Hardee County Housing Authority
Hardee County Indigent Health Care Special District
Health Care District of Palm Beach County
Hendry County Supervisor of Elections
Hernando County Housing Authority
Higher Education Facilities Financing Authority
Highlands County Housing Authority
Hillsborough Community College District Board of Trustees
Holmes County Housing Authority
Immokalee Water and Sewer District, Collier County
Indian River County Housing Authority
Indian River State College District Board of Trustees
Jacksonville Aviation Authority
Jacksonville Port Authority
Jefferson County Clerk of the Courts
Judges of Compensation Claims
Judicial Qualifications Commission
Juvenile Justice and Delinquency Prevention State Advisory Group
Juvenile Welfare Board of Pinellas County
Lake Shore Hospital Authority of Columbia County
Lake-Sumter State College District Board of Trustees
Lee County Housing Authority
Lower Florida Keys Hospital District, Monroe County
Madison County Health and Hospital Board
Manatee County Housing Authority
Medicaid Pharmaceutical and Therapeutics Committee
Medical Examiners Commission
Merritt Island Library District Board, Brevard County
Miami River Commission Policy Committee
Mid-Bay Bridge Authority, Okaloosa County
Monroe County Housing Authority
Ninth Circuit Judicial Nominating Commission
North Central Florida Regional Housing Authority
North Central Florida Regional Planning Council, Region Three
North Lake County Hospital District
Northeast Florida Regional Planning Council, Region Four
Northwest Florida Regional Housing Authority
Northwest Florida State College District Board of Trustees
Northwest Florida Water Management District Governing Board
One Church, One Child of Florida Corporation
Palm Beach County Housing Authority
Palm Beach State College District Board of Trustees
Pasco County Housing Authority
Pensacola State College District Board of Trustees
Pinellas County Housing Authority
Prison Rehabilitative Industries and Diversified Enterprises, Inc., Board of Directors (PRIDE)
Public Employees Relations Commission
Public Swimming and Bathing Facilities Advisory Review Board
Rare Disease Advisory Council
Regulatory Council of Community Association Managers
Rehabilitation Council for the Blind
Santa Fe College District Board of Trustees
Sarasota Manatee Airport Authority
School Board of Osceola County
Seagrass Restoration Technology Development Initiative Technology Advisory Council
Second Circuit Judicial Nominating Commission
Second District Court of Appeal Judicial Nominating Commission
Seminole County Housing Authority
Seminole State College of Florida District Board of Trustees
Seventeenth Circuit Judicial Nominating Commission
Seventh Circuit Judicial Nominating Commission
Sixteenth Circuit Judicial Nominating Commission
Sixth District Court of Appeal Judicial Nominating Commission
South Broward Hospital District
South Florida Regional Planning Council, Region Eleven
South Florida State College District Board of Trustees
South Florida Water Management District Governing Board
Southeast Interstate Low-Level Radioactive Waste Management Commission
Southeast Volusia Hospital District
Southern States Energy Board
Southwest Florida Regional Planning Council, Region Nine
Southwest Florida Water Management District Governing Board
Space Florida Board of Directors
St. Johns River Water Management District Governing Board
State Apprenticeship Advisory Council
State College of Florida, Manatee-Sarasota District Board of Trustees
State Council for Interstate Adult Offender Supervision
State Council for Interstate Juvenile Offender Supervision
State Emergency Response Commission
State Historical Records Advisory Board
State of Florida Correctional Medical Authority
State Retirement Commission
Statewide Drug Policy Advisory Council
Statewide Nominating Commission
Suicide Prevention Coordinating Council
Supreme Court Judicial Nominating Commission
Suwannee River Water Management District Governing Board
Tallahassee Community College District Board of Trustees
Tampa Bay Regional Planning Council, Region Eight
Tampa Port Authority
Tampa-Hillsborough County Expressway Authority
Tenth Circuit Judicial Nominating Commission
Third Circuit Judicial Nominating Commission
Third District Court of Appeal Judicial Nominating Commission
Thirteenth Circuit Judicial Nominating Commission
Tobacco Education and Use Prevention Advisory Council
Treasure Coast Regional Planning Council, Region Ten
Twelfth Circuit Judicial Nominating Commission
Twentieth Circuit Judicial Nominating Commission
University of West Florida Board of Trustees
Valencia College District Board of Trustees
Washington County Supervisor of Elections
Wekiva River Basin Commission
West Florida Regional Planning Council, Region One
Select seat(s) to add:
*
Your selected seat(s): (select item and click "Remove" to remove from list)
If you submit without selecting at least 1 seat your data will not be saved
Step 5: Attach additional documents (optional)
Note: Files must be 5 MB or less in size (Please contact the Appointments office if you have a larger file to upload)
Additional file 1:
Additional file 2:
Additional file 3:
Step 6. Public Records Exemption
Applications for appointment are public records, which may be requested by anyone; however, Florida law does provide some exemptions from the public records law for identifying information of certain covered individuals including their spouses and children.
*** If you believe that an exemption from the public records law applies to your submission, please download and complete the
public records exemption request form
, upload the form, and check the boxes below.
By checking the box you are submitting a written request for the EOG to maintain the exemption of your identifying information as provided by law (see section
119.071(4)3., Florida Statutes
).
Yes, I assert that my identifying information provided in this application is exempt from Florida’s public records law.
I have attached my Public Records Exemption Request form and I am ready to continue .
Step 7: Submit complete Board Application
*Please don't close your browser during upload*
Notes
*Mandatory Field
**This information will be used to provide demographic statistics and is not requested for the purpose of discriminating on any basis.
***Covered individuals include but are not limited to: current or former law enforcement officers, correctional and correctional probation officers, firefighters, service members serving after September 11, 2001, judges, assistant state attorneys, assistant and statewide prosecutors, assistant public defenders, personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement, and certain investigators in the Department of Children and Families (see section
119.071, Florida Statutes
).
If you need additional guidance as to the applicability of any public records law exemption to your situation, please contact the Office of the Attorney General:
The Office of the Attorney General
PL-01, The Capitol
Tallahassee, Florida 32399
(850) 245-0158