MPO Advisory Committee Membership Form

MPO-soloThe information from this questionnaire will be used by the Metropolitan Planning Organization (MPO) in considering appointments to advisory boards.

Applications are public record and will be kept on file and may be released to the public upon request.

 

1.  Which Board or Committee are you interested in?

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6.  Do you prefer to be contacted and receive paper and electronic documents at your home or work address?

Home Work

Please Note : The following information will be used to satisfy Equal Opportunity reporting and research requirements.

7.  Gender :

Male Female Other

8.  Race :

White / non-Hispanic Hispanic Black American Indian / Alaskan Native Asian / Pacific Islander

9. 

10.  Are you a United States citizen?

Yes No

If you chose "No", please explain :

11. Please indicate if you have a disability:

Yes No

12.  Have you ever been convicted of any felony or misdemeanor offense? Is so, please explain below. You may omit minor traffic violations and any offense committed as a minor :

13.  Are you a registered voter?

Yes No

14. In the past 12 months, did you, and any member of your household, receive: Medicaid benefits; supplemental security income (SSI); or, special supplemental nutrition program for women, infants, and children (WIC) benefits?

Yes No

15.  Continuous resident of Hillsborough County since :

Note: Hillsborough County residency is not mandatory for all types of appointments.

16.  Education :

List all post-secondary educational institutions attended:

17.  Have you ever held a professional license or certificate?

Yes No

If “Yes, please provide title, issue date, and issuing authority. If any disciplinary action has been taken, please state the type and date of the action taken :

18.  State your experience and interest or elements of your personal history that qualify you for appointment :

19.  If you are appointed, do you know of any reason whatsoever why you will not be able to attend regularly scheduled meetings or otherwise fulfill the duties of the office to which you have been appointed?

Yes No

If "Yes", please explain :

20.  Name any business, professional civic or fraternal organizations of which you are a member, and the dates of your membership.

21.  Do you or any member of your family sell goods or services to Hillsborough County, City of Tampa, Plant City or Temple Terrace?

Yes No

If "Yes", please explain :

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