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David S. Wieders NAME: ~~" ~" ~~C First Name vC~ Miaale miuai L~~ ~ f ~ Ouse No./Street ~ City State Zip Code `3L,s" ~~~~ ~~~ ~ ~~~~~6~ X063 clw~e~e~~ Work /~~ ~ ~} Fax ,~J Emad address Business Name ~ ~~ W 6~ ~!~ . 1 ' ~"~• Position: ~~~`~~ Last Name ~r HOME ADDRESS: 3~ G Apt N(/o.~~(~ PHONE: ~©~~jb~ 13 13 ~~ Home ~~/~ D s Address: 3~'d ~/ S1 ~ l.~it7/ ~'~T N ~- ~ ~ ~ `!L~ No. _~~j/~ Street ~ ~ City ,, / State Professional License (describe) ~u~K ~~~ / ~%, ~ ~~~ Expires: /V /~ up Loae 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~i or No -! /'' • (Please circle one): I am now a resident of: ~ North Beach South Beach Middle Beach .~• II am applying for an appoint ent beca~ e I~h~ave special abiliti ,knowledge, experience. Please list below: :" r~Lo~~~se~ I~ ~re~ter~ obb~ fw~i~li the C~t~ M a ~ ach? Yes C I or No HeY P Y 9 Y Please list your preferences in order of ranking [1] first choice [2] second choice, and (3] third choice. Please note that only three (31 choices will be observed by the City Clerk's Office. (Regular Boards of City) Affordable Housin Adviso Committee Historic Preservation Board ~i ^ Art in Public Places Committee ^Housin Authorit ^ Beach Preservation Board ^ Loan Review Committee ^ Beautification Committee ^ Marine Authorit ^ Board of Ad'ustment" ^ Miami Beach Commission for Women ^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council ^ Ca ital Im rovements Pro~ects Oversi ht Committee ^ Miami Beach Sister Cities Pro ram ^ Committee on the Homeless ^ Normand Shores Local Gov't Nei h. Im rovement ^ Committee for Qualit Education in MB ^ Parks and Recreation Facilities Board ^ Communit Develo ment Adviso ^ Personnel Board ^ Communit Relations Board tannin Board" ~ ^ Convention Center Adviso Board ^ Police Citizens Relations Committee ^ Cultural Arts Nei hborhood District Overla CANDO ^ Production Indust Council ^ Debarment Committee ^ Public Safet Adviso Committee esi n Review Board" ^ Safet Committee ^ isabilit Access Committe ^ Sin le Famil Residential Review Panel ^ Fine Arts Board ^ Sustainabilit Committee ^ Ga Business Develo ~rrierrflAd Wbc ~; ~I ^ r ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC" ^ Golf Adviso Committee ~~ ^ Trans ortation and Parkin Committee ^ Health Adviso C i€f~e°>` _ ^ Visitor and Convention Authorit ^ Health Facilities Authorit Board ^ Youth Center Adviso Board ^ His anic Affairs Comr-rfi ee ~` "" ~ • ~ ..3 ~;~ "Board Required to File State Disclosure form ~Avf~ 5; ~~~ F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application 21309.doc c. ~ ~`" -~ 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 Board: 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~l If 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 Ci or No~lf yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes~i or No ^. If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: •I-~L,is~t`~all properties own,~ed or have an in(~te~reAs~t in~,}which a,~reJlocated within of Miami Beach: • I am now employed by the City of Miami Beach: Yes ^ or N~Which department? • Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ^, child ^, brother ~I, or sister n who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): Gender: Male Ethnic Origin: Asian or Pacific Islander ^ Female ^ Race: White ^ Black ^ African-American/Black ^ American Indian or Alaskan Native ^ Hispanic: ^ White -Not Yes^or "I he y attest to ~ accu cy and truthfulness of the application and have received, read and will abide by Chapter 2, A le V - o Cod "Stand ds of Conduct for it Officers, Employees and Agency Members." vl /~ ~ i.(/1~1~~/~ App ican 's gn ure D e Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application NOTE: Applications will remain on file for a period of one (1) calendar year. Employment Status: Employed ^ Retir d ^ Home-maker ^ Other ^ O -z.~.~ I Received in City Clerk's Office by ~ ~ Date I Name of Deputy Jerk -, ; 7 ~: ~. fy~ ~ ~~, Document Control Number (Assigned by the City Clerk's Office) ` ! ~` Entered By ~~~`""2~' Date -',, - C / RP~~~Pn n4m~ma i H F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application 21309.doc