Pasco County MPO Seeks Community Members for Advisory Boards and Committees
APPLICATION FOR ADVISORY BOARD / COMMITTEE
APPLICATION FOR ADVISORY BOARD / COMMITTEE PASCO COUNTY METROPOLITAN PLANNING ORGANIZATION (MPO) Please complete this form in its entirety and return to: METROPOLITAN PLANNING ORGANIZATION 8620 GALEN WILSON BOULEVARD, PORT RICHEY, FL 34668 TELEPHONE: 727.847.8171 / FAX: 727.847.8177 APPLICANT INFORMATION DATE: ____________________ NAME: ____________________________________________________________________________________ FIRST MI LAST RESIDENTIAL ADDRESS: ____________________________________________________________________ CITY: ______________________________ STATE: __________ ZIP: ______________________ MAILING ADDRESS (if different from residential): ________________________________________________ CITY: ______________________________ STATE: __________ ZIP: ______________________ HOME PHONE: ____________________________ WORK PHONE: _____________________________ CELL PHONE: ____________________________ FAX: _____________________________________ EMAIL ADDRESS: ________________________________________________________________________ ARE YOU A REGISTERED VOTER IN PASCO COUNTY? YES NO OCCUPATION / PROFESSION: _________________________________________________________________ EMPLOYER: _____________________________________________________________________________ BUSINESS ADDRESS: _______________________________________________________________________ CITY: ______________________________ STATE: __________ ZIP: ______________________ EDUCATION: _____________________________________________________________________________ LIST ANY CIVIC, COMMUNITY OR PROFESSIONAL ORGANIZATIONS TO WHICH YOU BELONG: __________________________________________________________________________________________ __________________________________________________________________________________________ ARE YOU EMPLOYED BY, OR AN OFFICER OF, A PRIVATE BUSINESS ENTITY THAT HAS CONTRACTUAL RELATIONSHIPS WITH PASCO COUNTY GOVERNMENT? YES NO If Yes, please describe: _____________________________________________________________________ LIST ALL OTHER PUBLIC BOARDS, BODIES OR COMMISSIONS YOU SERVE ON: __________________________________________________________________________________________ __________________________________________________________________________________________ WHICH ADVISORY BOARD / COMMITTEE ARE YOU INTERESTED IN SERVING ON? (Check all that apply) CITIZENS ADVISORY COMMITTEE (CAC) TECHNICAL ADVISORY COMMITTEE (TAC) BICYCLE/PEDESTRIAN ADVISORY COMMITTEE (BPAC) FREIGHT ADVISORY COMMITTEE (FAC) WHY DO YOU WISH TO SERVE ON THIS (THESE) ADVISORY BOARD(S) / COMMITTEE(S)? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ARE YOU INTERESTED IN ANY OTHER ADVISORY BOARD/COMMITTEE? __________________________________________________________________________________________ __________________________________________________________________________________________ PLEASE ATTACH A RESUME OR BIOGRAPHICAL SKETCH AND ANY OTHER INFORMATION YOU BELIEVE WILL ASSIST US IN OUR SELECTION PROCESS. _________________________________________________________ SIGNATURE OF APPLICANT DATE MPO-Form-01 Revised: 04/24/2023