citizen application for membership transportation planning ... · please complete the attached...

CitizenApplicationforMembershipTransportationPlanningOrganization(TPO)

CitizensAdvisoryCommittee(CAC)

Name:___________________________________________________________________________Organization(ifapplicable):___________________________________________________________Address:__________________________________________________________________________City/State/Zip:_____________________________________________________________________Phone(Home/Cell/Business):_________________________________________________________E-Mail:___________________________________________________________________________Race/Ethnicity(optional):____________________________________________________________Checktheboxthatapplies:

q Iamapplyingfornewmembership.q Iamareturningcommitteemember.Myinformationisstillcurrent.(bycheckingthisboxthereisnoneedtocompleteanewapplication.)

Myreasonsforwantingtobeinvolvedinthiscommitteeare:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Potentialconflictsofinterest:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Theseaffiliationsdonotnecessarilyprohibityoufrombeingonacommittee.Thisinformationisonlyrequestedtoinsurethatpotentialcommitteemembersdonothaveaconflictofinterest.)

Informationprovidedinthisdocumentbecomesapublicrecord.

StafftoTPO

Pleasereadandconfirmyourunderstandingofthefollowing:

• Avotingmembershipmaybeattainedinoneofthefollowingways:• Acitizenof theTPOstudyareamaybenominated formembershipbyaTPOmember,

localgovernment,theCAC,orotherorganizationsandbeapprovedbytheTPO;or• A citizen of the TPO study area may directly petition the CAC for nomination for

membershipandbeapprovedbytheTPO.• CACmembers shall notbeelectedofficialsoremployeesofpublicorprivateagenciesdirectly

involvedintransportationorland-useplanning.• AnymemberwhoexpectstobeabsentfromameetingshallinformtheTPOstaffassoonas

practicabletoreceiveanexcusedabsence.Ifamemberisconsistentlyabsentwithoutanexcusedabsence,theCACmayrecommendtotheTPOthatthememberberemovedfromtheCAC.Threeconsecutiveunexcusedabsencesbyamembershallbegroundsforsuchrecommendation.

• CACcitizenmembersareexpectedtoattendmeetingsintheplanningareabytheirownmeans.ThemeetingfacilitiesmeetallADArequirements

• CACmembersmustbelegalU.S.citizensandresidentsoftheTPOstudyarea.• CACcitizenmembersareapprovedbytheTPOandmembersserveatthepleasureoftheTPO.• TheTPOconductsanannualreviewofadvisorycommitteemembership.• ToserveontheCAC,theapplicantmusthaveattendedacommitteemeeting,berecommended

forapprovalbythecommittee,andattendtheTPOmeetingwheretheywillbepresentedformembership(whenschedulingpermits)andbeapprovedbytheTPO.BoththecommitteemembersandTPOmembersmayaskquestionsoftheproposednewcommitteeapplicant.TheadvisorycommitteemembersmayberemovedatanytimebytheTPO.

Ihavebeengiventheopportunitytoreviewtheaboveinformation,readtheby-laws,andIunderstandandwillcomplywithallstipulations.FL-ALCACBy-Lawsmaybefoundatwww.wfrpc.org._________________________ _________________________________________________PrintedName Signature DateIunderstandthatrefusaltosignwillresultintheterminationoftheapplicationtoserveoneithercommittee.Forquestionsconcerningthisapplication,pleasecontactBrittanyEllersat(850)332-7976x220.PersonsneedingaspecialaccommodationtoparticipateinanadvisorycommitteemeetingshouldcontactBrittanyEllersat850-332-7976x220ore-mailatbrittany.ellers@wfrpc.org.

Pleasecompletetheattachedbackgroundformorattacharecentresume.(Acompletedbackgroundformorresumemustaccompanythisapplication.)

BackgroundForm(Tobeusedifaresumeisnotavailable)

Name:___________________________________________________________________________Address:__________________________________________________________________________City/State/Zip:_____________________________________________________________________Phone(Home/Cell/Business):_________________________________________________________E-Mail:___________________________________________________________________________CommunityInvolvement:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________WorkExperience:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Education:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________