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2. Of those organizations describe any possible conflict of interest that could occur or the appearance of a <br />conflict of interest that may prevent you from fairly conducting a hearing: <br />/ U j� <br />3. Have you ever been disixtrred, suspended or received any other disciplinary action from any organized <br />association, or from the State of Florida? No Yes (please explain) <br />4. List any personal or business relationship you have ever had with any officer or employee of the office of <br />the property appraiser. nftice of the cledt of the circuit court office of the county attorney or the value <br />adjustment board of any of the counties to which you are applying: <br />5. List any clubs, organizations, associations, or other entities to which you belong or participate in and in <br />which a possible conflict of interest could occur or the appearance of a conflict of interest might arise that <br />would prevent you from fairly conducting the hearing between the property appraiser and the property owner <br />and taxpayer. <br />/Un ti <br />CERTIFICATION <br />Pursuant to Fla. Stat.: 194.035. a person cannot serve as a special magistrate if he/she is an elected or appointed <br />official of a county. a taxing jurisdiction, or the state; is an employee of a county. a taxing jurisdiction, or the state: <br />or in the same tar year that hetshe services the Board as a special magistrate, represents a party before the Board in <br />any administrative review of property taxes. <br />Are you an elected or appointed official or employee of a county, a taxing jurisdiction, or the state? Yes No <br />If yes, please provide details:!t/ ) <br />The undersigned cerlyiev. under penaltr pf disqualification Jrom consideration. that each item contained in this <br />applicution. or tun• other dexument furnished by or on behalf of the applicant is true and Complete its of rhe date it <br />hears. The undersigned aewhariree the 6ulue Adjustment Board to obtain inJinmatiem Jrom other sourcres to ver fr <br />each item contained herein. The undersigned acknowledges /hat, i% selecred, he'she will, folhnr all requirements and <br />rnanchttes of lag• in jultilling the duties of special magistrate. <br />a: <br />Signature of Applicant <br />C Lfi J E �'�� <br />Primed Name of Applicant <br />Page I <br />01'13.2015 <br />-10- <br />