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Contact Information

First Name*
Last Name*
Street Address*
Mailing Address, if different
City*
State*
Zip*
Home Phone*
Cell Phone*
Work Phone
Email address*
Employer or Business*
If retired, please indicate career field or name of business at retirement
Title/Position Held*
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Miscellaneous Information
Please answer "Yes" or "No" where indicated
Are you currently serving on any City Board(s) or Committee(s)?*
If yes, please specify
Available Boards and Committees*
You may make more than one selection
1. Board of Adjustment
2. Board of Adjustment & Appeals
3. Citizens Advisory Committee to the Space Coast Transportation Planning Organization
4. Citizen Representative to Economic Development Commission of Florida's Space Coast
5. Community Redevelopment Agency Board of Commissioners
6. Code Enforcement Board
1. Planning Commission
2. Retirement Board, Fire Employees
3. Retirement Board, General Employees
4. Retirement Board, Police Employees
5. The Rockledge Environmental Enhancement (TREE) Board
Have you ever served on a City of Rockledge board?*
1. Yes
2. No
If yes, please list board(s) and dates of service
Are you a resident of Rockledge?*
If yes, how long?
Are you a homeowner in Rockledge?*
Are you registered to vote in Rockledge?*
Are you engaged in a business in Rockledge?*
Please provide qualifications, experience and background that you feel would be beneficial to the board or committee selected
Note:
Applications will be kept on file for a period of two (2) years. Periodic contact will be made to inquire into your interest in appointment to the selected board or committee before your application is submitted to the City Council.

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