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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 interesi that,may.prevent you from fairly conducting -a hearing: <br />I Haveyou ever been dlisbaffCd S"IsM k4ed or received any other disciplinary action IrVarri any arganiu.d <br />associafion;,or trom the Swale of Florui No Yes, (plcasevxplain) <br />4, Li I st any :personal or business relationship you have ever had wIth:any,officer or employee of the.office of <br />the properrY appraiscri office of the clerk or the circuit court, office of the county attorney or the value <br />adjustment board orany ofthe counties,to which you areapplying: <br />5. List any clubs. organizations, associations, or other entities to which you. Wong or Nrficipwc in' and in <br />which,a possible conflict of interest could occur or the appeanuicc of a conflict of inieresi might arise that <br />would prevent you from fairly conducting the hearing between the property appraiser Wd.theproperty-owner <br />and taxpayer - <br />C F, R I'l F I C A T l'O N <br />Pursuant to Fla.,Stat. w 104.033. a person cannot serve as a speci'M magistrate if he,'she is an.clected.or.appoinIC4 <br />official of a county.a taxing <br />jurisdiction, or the state: is, an employee -of a county a taxing jurisdiction,or tbc.statc; <br />or in the same tax yea I r that heiihe services the.Roard as a special magistrute—represents a party before the Board yin <br />any administrative review of properly.taxes. <br />Are you,an elected or iippinted official tit employee ora cowity, a taxing jurisdiction, or the state? Ycsi<'d'/ / <br />if yes;' please provide details <br />The undersigned cvrt4ies, under penalty- of disqualificviion from; convideration, that each item contained in this <br />aPIRk.'afirl". Oreonri, wher document fiirmshtd by or oat bekaq'qffltt, upphrolif is true and complete 14V'Of thedah, it <br />bean, The undersigned atahorizev. the lWue Adjuvnient Board to obtain infnnnutionfirom other sotares upverify <br />each stent contailled hervill'. The Undersigned ack-nowleikggevL that., ifselwted, helshe ivill,rollo", all rquiremewand <br />mundtiley qfhiu, ftrfqfilliqg the duties Of4pecial mogistrahU. <br />,7 <br />Signature of Applicant <br />-A-1- .Printed iVame cif Applicant. <br />7L7�� <br />Page.1 <br />