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Citizen Application for Membership Transportation Planning Organization (TPO) Citizens Advisory Committee (CAC) Name: ___________________________________________________________________________ Organization (if applicable): ___________________________________________________________ Address: __________________________________________________________________________ City/State/Zip: _____________________________________________________________________ Phone (Home/Cell/Business): _________________________________________________________ E-Mail: ___________________________________________________________________________ Race/Ethnicity (optional): ____________________________________________________________ Check the box that applies: q I am applying for new membership. q I am a returning committee member. My information is still current. (by checking this box there is no need to complete a new application.) My reasons for wanting to be involved in this committee are: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Potential conflicts of interest: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (These affiliations do not necessarily prohibit you from being on a committee. This information is only requested to insure that potential committee members do not have a conflict of interest.) Information provided in this document becomes a public record. Staff to TPO

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Page 1: Citizen Application for Membership Transportation Planning ... · Please complete the attached background form or attach a recent resume. (A completed background form or resume must

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

Page 2: Citizen Application for Membership Transportation Planning ... · Please complete the attached background form or attach a recent resume. (A completed background form or resume must

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.)

Page 3: Citizen Application for Membership Transportation Planning ... · Please complete the attached background form or attach a recent resume. (A completed background form or resume must

BackgroundForm(Tobeusedifaresumeisnotavailable)

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


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