Form FDACS-10059 "Board of Professional Surveyors and Mappers Appointment Questionnaire" - Florida

What Is Form FDACS-10059?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FDACS-10059 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form FDACS-10059 "Board of Professional Surveyors and Mappers Appointment Questionnaire" - Florida

292 times
Rate (4.8 / 5) 20 votes
FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
NICOLE "NIKKI" FRIED
COMMISSIONER
BOARD OF PROFESSIONAL SURVEYORS AND MAPPERS
APPOINTMENT QUESTIONNAIRE
Section 472.007(2), Florida Statutes
Rule 5J-17.086, Florida Administrative Code
FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
NICOLE "NIKKI" FRIED
COMMISSIONER
BOARD OF PROFESSIONAL SURVEYORS AND MAPPERS
APPOINTMENT QUESTIONNAIRE
Section 472.007(2), Florida Statutes
Rule 5J-17.086, Florida Administrative Code
Florida Department of Agriculture and Consumer Services
Board of Professional Surveyors and Mappers
Appointment Questionnaire
This questionnaire is being required for all prospective appointees to boards, councils, authorities or committee who have
decision making responsibilities. It is also required for appointment for individuals who will make recommendations to the
Department concerning the disbursement of funds for particular reasons.
The first part of the questionnaire is to be used to comply with reporting minority representation on boards, commissions,
and committees. This is required in Section 760.80, Florida Statutes. The second part of the questionnaire is information
we need to determine your qualifications for the desired appointment and basic background information.
Please be assured that we appreciate you taking the time to fill out the questionnaire. We have attempted to make the
questionnaire a document which will only give us the information we need to contact you and to determine your
qualifications and desires to be appointed. Thank you in advance for your cooperation.
For additional information contact:
Office of External Affairs
Florida Department of Agriculture and Consumer Services
PL-10, The Capitol
400 South Monroe Street
Tallahassee, Florida 32399-0800
(850) 488-3022
FDACS–10059 Rev. 02/17
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
BOARD OF PROFESSIONAL
Send completed application to:
SURVEYORS AND MAPPERS
Office of External Affairs
APPOINTMENT QUESTIONNAIRE
Florida Department of Agriculture and
Consumer Services
Section 472.007(2), Florida Statutes
PL-10, The Capitol
Rule 5J-17.086, Florida Administrative Code
400 South Monroe Street
NICOLE "NIKKI" FRIED
Tallahassee, FL 32399-0800
1-800-HELP-FLA (435-7352)
(850) 410-3800 www.FDACS.gov
COMMISSIONER
The questionnaire MUST BE COMPLETED IN FULL. Answer “none” or “not applicable” where appropriate. Please
provide details in the space provided or include a separate sheet of paper attached to this document.
Date Completed:
/
/
Name:
Have you ever been known by any other legal name?
Yes**
No
** If Yes, please explain:
Preferred Mailing Address:
Home
Business
Home Address
:
(if applicable please include suite and/or unit numbers)
City:
State:
Zip Code:
-
Contact Number(s):
Email Address:
(
)
-
(
)
-
Home Phone
Cellular Phone
Business Address
:
Business Telephone:
(if applicable please include suite and/or unit numbers)
(
)
-
City:
State:
Zip Code:
-
Board of Interest:
Board of Professional Surveyors and Mappers
Current Employer:
Occupation:
Are you applying for reappointment:
Yes
No
Date of Birth:
Gender:
/
/
Male
Female
Race:
Asian or Pacific Islander
Black or African American
Native American or Alaskan Native
Spanish, Hispanic, or Latino
White or Caucasian
Other
FDACS-10059 Rev. 02/17
Page 1 of 6
Do you have a disability?
Yes**
No
** If Yes, please describe your disability briefly. Please remember that any medical information you disclose may be
available for public inspection under the state of Florida’s broad public records law.
Do you now, or 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 you belonged on the basis of race, religion,
national origin, or gender?
Yes**
No
** If Yes, detail the name and nature of the club(s) or organizations, relevant policies and practices, and state whether you
intend to continue as a member if you are appointed by the Commissioner.
The above information will be used to comply with Florida Statute Section
760.80, “Minority representation on boards, commissions, councils, and committees.”
APPLICANT INFORMATION
Are you a United States citizen?
Yes
No**
** If No, please explain:
Are you a registered voter?
Yes**
No
** If Yes, party affiliation:
Education:
High School Attended:
Year Graduated:
List all post-secondary educational institutions attended:
Name and Address of Institution
Year of Graduation
Certification / Degree
Have you received any degree(s), professional certification(s), or designation(s) related to the subject matter of
this appointment?
Yes**
No
** If Yes, please describe:
Are you or have you ever been a member of the armed forces of the United States?
Yes
No
If Yes
, please provide the following:
**
**
Dates of service:
Branch or component:
Date and type of discharge:
Have you ever been convicted of a felony or first degree misdemeanor?
Yes
No
If Yes
, please provide the following:
**
**
On what charges:
Where convicted?
Date of conviction:
FDACS-10059 Rev. 02/17
Page 2 of 6
Have you ever pled nolo contendere or plead guilty to a crime which is a felony or first degree misdemeanor?
Yes
No
If Yes
, please provide the following:
**
**
On what charges:
Where?
Date:
Have you ever had adjudication of guilt withheld to a crime which is a felony or a first degree misdemeanor?
Yes
No
If Yes
, please provide the following:
**
**
On what charges:
Where?
Date:
Please Note: A “yes” answer to these questions will not automatically bar you from appointment. The nature, appointment relatedness,
severity and date of the offense in relation to the appointment for which you are applying will be taken into consideration.
Please list your last three employers or all employers during the last five years. Attach additional sheets as
necessary.
Employer / Company Name:
Employer / Company Address:
City:
State:
Zip Code:
-
Type of Business:
Occupation/Job Title:
Dates of Employment:
From:
To:
Employer / Company Name:
Employer / Company Address:
City:
State:
Zip Code:
-
Type of Business:
Occupation/Job Title:
Dates of Employment:
From:
To:
Employer / Company Name:
Employer / Company Address:
City:
State:
Zip Code:
-
Type of Business:
Occupation/Job Title:
Dates of Employment:
From:
To:
Do you currently hold an office or position (appointive, civil service, or other) with federal or any foreign government?
Yes**
No
** If Yes, please explain:
Are you currently involved with, employed by, volunteer with or have a contractual relationship with any state,
district, or local government agency in the state of Florida?
If yes
, identify the position(s), the names of the employing agency, and the periods of
**
Yes
No
**
employment:
FDACS-10059 Rev. 02/17
Page 3 of 6