Tiffany Hecklerm ~,."IBEACH
CIT',` -F MIAMI BEAC4~
B0,4R1/' L;NrD CrJMtViI T T EE kPPLiCk T dGl~ FOP,ftr1
NAME: ~E ~ ~ L~ ~ ~ ~~ ~ N'I ~+.
//Last Name First Name Middle Initial
HOME ADDRESS: b ~ a 3 ~ QV A ffiV~N,~ ~ ~ (p0~ /'vll-~'Wt 1 $~bl Gy ~t~ ~~)
No. Street City State Zip Code
PHONE: 3°S. ~~o~0-~ro6 3 (3os~yy~-oS~fe Tl_~ b Z(o~y-A~'OD.CA"t,
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Home
Business Name:
Address:
No.
Professional License (describe)
Fax
Position:
Street City
Email add
State Zip Code
Expires: Attach a cop}~ or the license
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
. Resident of Miami Beach for a minimum of six (6) months: Yes ~or No ^
. Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes ^ or No ~
• Are you a registered voter in Miami Beach: Yes ~ or No ^
• (Please circle one): I am now a resident of: orth B ~ch~ South Beach Middle Beach
• I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
„~ 1'.,.~ o~ ~v~l~n~-~ --~e,. woy~n~ s ~~~ o~ tM~awt i -D~o~Y s~!~ cc Z o 0 2.
Please list your preferences in order of ranking (1] first choice [2] second choice, and [3] third choice. Please note that oniy three i3)
choices will be observed by the Citv Clerk's Office. (Regular Boards of City)
^ Affordable Housin Adviso Committee ^ Historic Preservation Board*
^ Art in Public Places Committee ^Housin Authorit *
^ Beach Preservation Board D Loan Review Committee"`
D Beautification Committee ^ Marine Authorit
D Board of Ad~ustment* ^ Miami Beach Commission for Women
^ Bud et Adviso Committee D Miami Beach Cultural Arts Council
0 Capital Im rovements Oversi ht ^ Miami Beach Florida Sister Cities
D Committee on Homeless ^ Normand Shores Local Gov't Nei h. Im rovement
Committee for Qualit Education in MB ^ Parks and Recreation Facilities Board
ommunit Develo ment Adviso ^ Personnel Baard'
ommuni Relations Board ^ Plannin Board
Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Cultural Arts Nei hborhood District Overla (CANDO ^ Production Indust Council
D Debarment Committee ^ Public Safet Adviso Committee
^ Desi n Review Board" ^ Safet Committee
^ Disabilit Access Committee ^ Sin le Famii Residential Review Panel
0 Fine Arts Board ^ Sustainabilit Committee
D Ga Business Develo ment Ad Hoc ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC"
' ^ Golf Adviso Committee i ^ Trans ortation and Parkin Committee
^ Health Adviso Committee ^ Visitor and Convention Authorit
^ Health Facilities Authorit Board I ^ Youth Center Adviso ~ Board
^ Hispanic Affairs Committee
* Board Required to File State Disclosure form i
_~r;`~'~,F;~'_1Ecar ~ ~,omi-~ittees'~~~<_. ~.c~~r.~aio~~~o~., ~„~r~ir~aUo~ Gevi~s~ ;;Oc.dv_
Note. If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center.
1. Past service on the Youth Center Advisory Beard. Yes No Years of Service:
2. Present participation in Youth Center activities by your children Yes- No If yes.. please list the names of your children, their
ages, and which programs. List below.
Child's name: Age: Program.
Child's name: Age: Program:
.Have you ever been convicted of a felony: Yes = or No~lf yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ~~ or No~, If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ~ or No ~If yes, explain in detail
• Are you currently servin on any Cit Boards or Committees: Yes ~or No ~. If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach.
. I am now employed by the City of Miami Beach: Yes C or No~ Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ~, spouse ~, child ~, brother ~, or sister ~ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ~ (1
This section is "not required" but desired: Age: ~ years old Gender: Male ^ Female
Ethnic Origin (Check one)
White African-ArnericanBlack ^ Hispanic: 0 Asian or Pacific Islander Ci American Indian or Alaskan Native D
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII - of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
i
Ap ticant's Signature Date Name of Applicant (PLEASE
PRINT)
Please attach a copy of your resume to this application ~ ~`L~~
NdTE: Applications will remain on file for a period of one (1 j calendar year.
Employment Status: Employed~Retired 0 Home-maker ~~ Other
Received in City Clerk's Office by
Name of Deputy Clerk
Document Control Number (Assigned by the City Clerk's Office) Entered By
Date
Date
Revisetl 09/02/08 Lr.
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