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SPECIAL MAGISTRA.TKAPPLICA-TON - <br />• Ikhi WRIER COUNTY VALUEADJt35P%NT„BOARD <br />3. Have you -ever been :disbarred, suspended or •received' any, other::diseipj nary action, from any oiganized. <br />association, or froiii the State of Florida? o ..0 yes .(pleak ek�laiti) <br />4. List any pet oo l- • r'Vusiness ielationship'you have ever had *ith; any:officbr or••empldyee ofthe offtce.of:the. <br />property appraiser.:.oh ce'of ihe-•clerk of -the circuit •court, bffice�o�;•tlie,county-attorney_or the vakae adjustment <br />board -df any.of the coi�lfthes to-whicli you are applying: <br />A1�.�' <br />5. List any clubs, -qt& iiiat ons, associations, or other.'entities to vvhich•you.belong or participate in and in which a <br />possible conflict dfYuterest could'o'ecur or the, appeafanCe of' -a confi'1..bf of- irifeiest.:mighi arise that would prevent <br />you from.faii$y'conducting the hearing be e n the . r erty.appi si'ser'arid the prop0rty owner ana taxpayer'. <br />I <br />.Pursuant to -.Fla.. Stat:; § : 1*94;035, a .person•'cannot serve as` a. speciai niagistraie if he/she is an. elected.or appointed . <br />.official of a county,:a ;taxinglurisdiction,.or• the .§tate; is an enlpIoyee.-o q%:toudty; a taxing jiiri$diction, :or ih6 state; <br />or in thesame tax:y'ear'•tfiaf-fidA ie serviees`the-Bbard as a ppediik] magistrate; repiesetits a:party before the Board -in <br />any administrative r'evieiv.of pr'operfy taxes. <br />:Are you an elected or• appoinied_officidI or employee:of a county;;ataxirig jut'isdictiori, or the state? Yes' j No <br />If yes, please provide • letaiis: <br />•The undersigned •certifiesunder: pendlty, of:disqurll fcation from'considemdorii .that each item cont ained' in •this <br />application, or any.other. dbCrlitierit furnished by or ,ori •beha jof the'dpp;'licant is °true and complete as of the date it <br />bears. ThewidersigW-aruthori2ei the VctlueAdjustrnent'Baard•io'obtain iiforsnation from other sources:to verify <br />each item' contained%teYeii�..i''7!e,un[leesigned.rtcknowledges tha't,= f�elected A Ishe,will"folldiv all requireinenfs and <br />'mdndates of'law fn fullrig the duties of special`magistt�at <br />�_' .�������i '/ � Date- � / �� .��V •. ' ' • <br />e of Applica t: <br />117 <br />%ne ame of Ap Iic�nt <br />Page � <br />- .52 - : . <br />