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2. Full Name*
3. Present Occupation
5. Contact Phone*
6. Email Address*
8. Street Address*
9. City, State, Zip*
11. Membership in Community Organizations or Professional Groups
13. List Former Advisory Board(s) Affiliations
15. Comments
17. Indicate Board You Would Like to be Considered For*
    -- Select One --Board of AdjustmentCommunity Redevelopment BoardLocal Planning AgencyStuart Independent Review BoardEast Stuart Historical Advisory Committee
19. The Florida Department of State requires that the City report the number of minority appointments made during the year. (Section 760.80, Florida Statutes)
21. Gender*

    1. Male
    2. Female
    3. Not Known
22. Race*

    1. African American
    2. Asian American
    3. Caucasian
    4. Hispanic American
    5. Native American
23. Disability*

    1. Not Known
    2. Physically Disabled
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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