Directory Consent Form

RESIDENT DIRECTORY CONSENT FORM

BallenIsles Address:*

Would you like to have your information listed in the Resident Directory?*

YesNo

If Yes, please select one of the options below:

There are no changes, all information remains the same as the last directory publication. Please complete Section 3.My information has changed, I am a new homeowner, or my information was not listed in the last directory. Please complete Section 2 and Section 3.

Please complete all fields below. Print exactly as you wish your information to appear.

Name 1:

First NameLast Name

Title for Name 1:

Name 2:

First NameLast Name

Title for Name 2:

Secondary Address (one only):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

BallenIsles Phone Number:

Please enter a valid phone number.

Secondary Phone Number:

Please enter a valid phone number.

Cell 1:

Please enter a valid phone number.

First Initial of Name for Cell 1:

Cell 2:

Please enter a valid phone number.

First Initial of Name for Cell 2:

Email 1:

example@example.com

Email 2:

example@example.com

Pursuant to Florida Statute 720.303(5), I/we voluntarily give consent for the Ballenisles Community Association (and any employee, committee member or other person assisting the Association) to disclose and publish the information contained in this Consent in the directory of residents for the Ballenisles Community. The information contained in this Consent may be posted online in a website for the Ballenisles Community. While the owner directory is intended only for BallenIsles residents, we release and hold Ballenisles Community Association (and any employee, committee member or other person assisting the Association) harmless if third parties obtain the information in this Consent. If we include email information in this Consent, then we also consent to the Community Association emailing meeting notices and other Community Association notices to us. By my signature below. I agree to the above consent.

Initials:

The Resident Directory will be distributed electronically and published on the Resident portal. If you would like to receive a hard copy, please indicate how many copies you would like to receive below. If you do not request a hard copy, we cannot guarantee that one will be available to you.

Would you like to receive a hard copy:*

YesNo

If Yes, please select the number of directories requested:

12

Signature*

Date*

Date

Print Name*

Section 1:

Section 2:

Section 3: