GOVERNOR'S OFFICE Boards and Appointments Application

Similar documents
GOVERNOR'S OFFICE Boards and Appointments Application


GOVERNOR'S OFFICE Boards and Appointments Application

GOVERNOR'S OFFICE Boards and Appointments Application

GOVERNOR'S OFFICE Boards and Appointments Application

GOVERNOR'S OFFICE Boards and Appointments Application

Gubernatorial Appointments Form for General Information** Governor s Appointments Office (850) or

GOVERNOR'S OFFICE Boards and Appointments Application

GOVERNOR'S OFFICE Boards and Appointments Application

JACKSONVILLE CITY COUNCIL Board and Commission Appointment Application

OFFICE OF THE GOVERNOR

STATE OF FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES

GOVERNOR GREG ABBOTT OFFICE OF THE GOVERNOR APPOINTMENT APPLICATION

APPLICATION FOR CAPITAL COLLATERAL REGIONAL COUNCIL

To: Chancellors, Presidents, and Chief Academic Officers of Public Institutions of Higher Education

State of Florida Department of Business and Professional Regulation Asbestos Licensing Unit Request for Change of Status Form # DBPR ALU 4

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

TEXAS HIGHER EDUCATION COORDINATING BOARD P.O. Box Austin, Texas 78711

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

1 of 9. APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your application to ensure faster processing.

MUST BE COMPLETED IN FULL.

WALTON COUNTY PROPERTY APPRAISER S OFFICE APPLICATION FOR AT-WILL EMPLOYMENT

EMPLOYMENT APPLICATION Town of Topsham 100 Main Street Topsham, Maine Phone: Fax:

CHAPTER Senate Bill No. 2058

Please mail your completed application, documentation and required fee(s) to: 2601 Blair Stone Road Tallahassee, Fl

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

State of Florida Department of Business and Professional Regulation Board of Professional Geologists

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

Attention Applicants

ADULT GUARDIANSHIP QUESTIONNAIRE A. INFORMATION ABOUT THE ALLEGED INCAPACITATED PERSON:

CITY OF LAKE WORTH, TEXAS APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer

Green Thumb Volunteer Application.

APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your application to ensure faster processing.

KIHIKIHI SCHOOL. Whitmore Street, Phone: Kihikihi Fax: Web:

Name Last First M.I. Would you be interested in your application packet being forwarded to the TERO Office to be included in a job

6Gx13-8C School Board--Methods of Operation LOBBYISTS. I. Purpose

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

APPLICATION FOR LICENSURE AS MARRIAGE AND FAMILY THERAPIST SUPERVISOR

Last Name First Name Middle Name Social Security Number. Street Address City State and Zip Code. Yes No If not, state Date of Birth

APPLICATION For Employment

FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. APPLICATION REQUIREMENTS

SUFFOLK REDEVELOPMENT AND HOUSING AUTHORITY 530 East Pinner Street, Suffolk, Virginia Phone: Fax:

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. APPLICATION REQUIREMENTS

SCHOOL DISTRICT OF MARATHON CERTIFIED STAFF EMPLOYMENT APPLICATION

FORM F4 REGISTRATION OF INDIVIDUALS AND REVIEW OF PERMITTED INDIVIDUALS (section 2.2)

PERSONAL HISTORY QUESTIONNAIRE. Applicant Name:

STATE OF NEW JERSEY OFFICE OF THE ATTORNEY GENERAL DEPARTMENT OF LAW & PUBLIC SAFETY DIVISION OF ALCOHOLIC BEVERAGE CONTROL

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. APPLICATION REQUIREMENTS

REINSTATEMENT QUESTIONNAIRE. To facilitate the processing of Petitions for Reinstatement to practice law the

STATE OF NEW JERSEY PETITION FOR EXECUTIVE CLEMENCY

ADULT GUARDIANSHIP QUESTIONNAIRE

UNIFORM JUDICIAL QUESTIONNAIRE

Employment Application An Equal Opportunity Employer

FILING TO RUN FOR OFFICE

2017 PERSONAL HISTORY QUESTIONNAIRE. Applicant Name: Instructions

Employment Application

Return completed form to: City of Collinsville. City Clerk s Office 125 South Center Collinsville, IL 62234

APPLICATION FOR LIQUOR RETAILER S LICENSE / ALCOHOL ON PREMISE LICENSE PART 1

CITY OF MCLOUTH, KANSAS

CITY OF SAYRE, OKLAHOMA AN EQUAL OPPORTUNITY EMPLOYER

RE-APPLICATION FOR LPC-SUPERVISOR and LMFT-SUPERVISOR LICENSES [Applicable for lapsed license over two (2) years]

Employment Application City of Fergus Falls ~ 112 West Washington ~ Fergus Falls, MN ~ Phone (218)

National Marine Sanctuary Advisory Council. Application Form

APPLICATION FOR INITIAL LICENSE

Amory Police Department Chief Ronnie Bowen, 200 South Front Street, Amory, MS (662) FAX (662)

Michael Gayoso, Jr. Office of the County Attorney TH

Please mail your completed application, documentation and required fee(s) to: 2601 Blair Stone Road Tallahassee, Fl

Last Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?

Application for Massage Establishment License

APPLICATION FOR NOMINATION TO THE

STATE OF KANSAS OFFICE OF THE ATTORNEY GENERAL Through the KANSAS BUREAU OF INVESTIGATION INSTRUCTIONS

THE REQUIREMENTS FOR ALCOHOLIC BEVERAGE APPLICATION MUST BE A UNITED STATES CITIZEN ANYONE THAT OWNS 20% OR MORE OF THE BUSINESS +THE MANAGER

APPLICATION FOR EMPLOYMENT

Name Home Phone( ) LAST FIRST MIDDLE Cell Phone( ) Address: Address NO STREET CITY STATE ZIP

APPLICATION CHECKLIST IMPORTANT

Instructions for Applying to be Reinstated After 5 Years

Piedmont Regional Jail Authority Post Office Drawer 388 Farmville, VA (434)

North Carolina Extension Master Gardener Volunteer Application Wake County

APPLICATION FOR VOLUNTEERS Mental Illness Recovery Center, Inc.

CLERK OF THE COURT SUPERIOR COURT OF ARIZONA

TEXAS BOARD OF PARDONS AND PAROLES FULL PARDON APPLICATION INSTRUCTIONS

PROFESSIONAL APPLICATION Main and Mitchell Road P. O. Box 288 Booker, TX Ph: (806)

ROUGH ROCK COMMUNITY SCHOOL, INC. HC 61 Box 5050 PTT Rough Rock, Arizona Phone: (928)

Absentee Shawnee Tribe

Name Prefer to be called (First) (Middle Initial) (Last) Mailing Address (Street, P.O. Box, Route, Apt #) (City) (State) (Zip)

IMMIGRATION INTAKE QUESTIONNAIRE

FLORIDA COUNCIL ON THE SOCIAL STATUS OF BLACK MEN AND BOYS COMMUNITY REPRESENTATIVE APPLICATION

THE MORTGAGE BROKERS ACT

NORCAL Ambulance Employment Application. ( ) - ( ) - Home Phone Cell Phone Address

THE FOLLOWING ITEMS MUST BE SENT IN WITH YOUR APPLICATION IN ORDER FOR IT TO BE CONSIDERED COMPLETE:

LOAN-OUT COMPANY START FORM AND AGREEMENT

CONSTITUTIONAL AMENDMENT (Amendment approved by the voters on November 8, 2011)

Keokuk Police Department

PRE-EMPLOYMENT APPLICATION PACKET PAVEMENT SOLUTIONS, LLC

Choctaw Nation Gaming Commission P.O. Box 5229 Durant, OK Phone: (580) Fax: (580)

City of Lakewood Board of Appeals Appointment Application

Kingsland Municipal Utility District PO Box 748 Kingsland, Texas Phone (325) Fax (325)

LOBBYIST INFORMATION

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT, IN AND FOR COUNTY, FLORIDA. Case Number:

Transcription:

As a general matter, applications for all positions within state Government are public records, which may be viewed by anyone upon request. However, there are some exemptions from the public records law for identifying information relating to past and present law enforcement officers and their families, victims of certain crimes, etc. If you believe an exemption from the public records law applies to portions of your application, please check this box. Contact 1- General Title Ms. First Name Lena Middle/Maiden Jones Last Name Lofton Email Address Lwez008@att.net Cell Phone 305-281-1986 Race African-American Gender Female Fax Disability Addresses Speficy the preferred mailing address: Residential 2- Residence Address Line 1 975 SW Jones Terr Address Line 2 City Lake City State Florida County Columbia Zip / Postal Code 32025 Phone Number 386-754-4694 3- Business Address Line 1 Address Line 2 City Zip / Postal Code State Phone Number Other Residences 4-A. List all your places of residence for the last ten (10) years. 1 of 6

Address City & State Start Date End Date 10792 SW 165 Terr Miami, Fl Dec.1988 May 2010 4-B. List all your former and current residences outside of Florida that you have maintained at any time during adulthood. Address City & State Start Date End Date Personal Information 5- Date of Birth 05/19/1946 6- Driver License # Place of Birth Issuing State Lake City, Fl 7- Social Security # 119.071(5)(a), F.S. 8- Have you ever used or been known by any other legal name? Yes Maiden Name: Lena Ellawese Jones 9- A. Are you a United States citizen? Yes B. If you are a naturalized citizen, date of naturalization 10- Since what year have you been a continuous resident of Florida? 11- Vote Are you a registered Florida voter? Yes County of registration Columbia Current Party Affiliation Democrat Education 12-A. High School Year Graduated B. List all postsecondary educational institutions attended Name & Location Start Date End Date Certificates / Degrees Received Employment 13- Are you or have you ever been a member of the armed forces of the United States? A. Date of Service B. Branch or component C. Date & Type of Discharge 2 of 6

14- Concerning your current employer and for all of your employment during the last ten years, list your employer s name, business address, type of business, occupation or job title, and period(s) of employment. Employer's Name & Address Type of Business Occupation / Job Title Start Date End Date Miami Dade Corrections Correctional Facility Correctional Counselor 1992 2008 MiamiDade Corrections Miami, Fl Jail facility Counselor Jan.1991 May 2008 15- Have you ever been employed by any state, district, or local governmental agency in Florida? Yes Position Employing Agency Start Date End Date Driver License Examiner State of Florida 1970 1984 Correctional Counselor Miami Dade County 1992 2008 Driver License Examiner State of Florida 1971 1985 Appointments 16- A. State your experiences and interests or elements of your personal history that qualify you for this appointment B. Have you received any degree(s), professional certification(s), or designations(s) related to the subject matter of this appointment? C. Have you received any awards or recognitions relating to the subject matter of this appointment? D. Identify all association memberships and association offices held by you that relate to this appointment 17- Do you currently hold an office or position (appointive, civil service, or other) with the federal or any foreign government? 18- Have you previously been appointed to any office that required confirmation by the Florida Senate? Title of Office Term of Appointment Confirmation Result 3 of 6

19- A. Have you ever been elected or appointed to any public office in this state? Office Title Date of Election or Appointment Term of Office Level of Government (city, county, district, state, federal) B. If your service was on an appointed board(s), committee(s), or council(s) 1- How frequently were meetings scheduled 2- If you missed any of the regularly scheduled meetings, state the number of meetings you attended, the number you missed, and the reasons(s) for your absence(s) Meetings Attended Meetings Missed Reason for Absence Violation 20- Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, regulation, or ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less was paid.) Date Place Nature Disposition 21- Has probable cause ever been found that you were in violation of the Code of Ethics for Public Officers and Employees, Part III, Chapter 112, F.S.? Date Nature of Violation Disposition 22- Have you ever been suspended from any office by the Governor of the State of Florida? Title of Office Reason of Suspension Date of Suspension Result Please Select 23- Have you ever been refused a fidelity, surety, performance, or other bond? Certifications 24- Have you held or do you hold an occupational or professional license or certificate in the State of Florida? Yes Error: Subreport could not be shown. 25- Have you ever been a registered lobbyist or have you lobbied at any level of government at any time during the past five (5) years? A. Did you receive any compensation other than reimbursement for expenses? 4 of 6

B. Name of agency or entity you lobbied and the principal(s) you represented Agency Lobbies Principal Represented Disclosures 26- If required by law or administrative rule, will you file financial disclosure statements? Yes 27- A. Have you, or businesses of which you have been an owner, officer, or employee, held any contractual or other direct dealings during the last four (4) years with any state or local governmental agency in Florida, including the office or agency to which you have been appointed or are seeking appointment? Name of Business Your Relationship to Business Business Relationship to Agency B. Have members of your immediate family (spouse, child, parents(s), siblings(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 (4) years with any state or local governmental agency in Florida, including the office or agency to which you have been appointed or are seeking appointment? Name of Business Family Member's Relationship to You Family Member's Relationship to Business Business Relationship to Agency References & Affiliations 28- List three persons who have known you well within the past five (5) years. Include a current, complete address and telephone number. Exclude your relatives and members of the Florida Senate. Name Mailing Address Zip Code Phone Number Joe Chancey 207 SW Lory Gln Lake City, Fl 32024 3866239187 Clayton Wilson 1388 Tuskenuggee Ave.Lake City, Fl 32025 3867557888 Lillette Lee 15540 SW 102 Ct. Miami, Fl. 33157 3052817351 29- Name any business, professional, occupational, civic, or fraternal organizations(s) of which you are now a member, or of which you have been a member during the past five (5) years, the organization address(es), and date(s) of your membership(s) Name Mailing Address Office(s) Held & Term Date of Membership 30- Do you know of any reason why you will not be able to attend fully to the duties of the office or position to which you have been or will be appointed? 5 of 6

31- Are you now, or in the past three years have you been, a member of any club or organization that, to your knowledge, in practice or policy, restricts membership or restricted membership during the time that you belonged on the basis of race, religion, national origin, or gender? If so, detail the name and nature of the club(s) or organization(s), relevant policies and practices, and state whether you intend to continue as a member if you appointed by the Governor? Boards of Interest Functional Category Medical & Health Misc Misc Misc Board Name Seat Seat Qualification Reappointment Lake Shore Hospital Authority of Columbia County Columbia County Housing Authority Columbia County Housing Authority Columbia County Housing Authority 4 Six members shall be citizens at large. 1 NA 2 NA 3 NA 6 of 6