Rita A. Goldberg~~ ~ ~~
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NAME: ~,,"'~CL
Last
HOME ADDRESS: 3 ~
Apt No
PHONE: w
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Business Name:
Address:
No. Street City State Zip Code
Professional License (describe)
Expires: >~
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 ownershiplnterest fora minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: YesV~or No ^
• Demonstrate an ownership~nterest 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 ~r No ^
. (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. elow:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No ~ ~~~~ -~Ll. ~~ bV(1
... ~ _ ~ ...r _ . „ ~ n- -- ~ ~1M0..~'_ ~ SSA 1"`"
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 Citv Clerk's Office. (Regular Boards of City)
^ Affordable Housin Advi Committee ^ Housin Autho '
^ Art in Public Places Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Authori
^ Board of Ad'ustment* ^ Miami Beach Commission for Women
^ Bud et Adv' Committee ^ Miami Beach Guttural Arts Council
^ Ca ' I Im ovements Pr 'eds Oversi ht Committee ^ Miami Beach Sister Cities Pr ram
^ Committee on the Homeless ^ Norman Shores Local Government Nei h. Im rovement
ommittee for Qual' Education in MB ^ Parks and Recreation Faalities Board
^ Commun' Develo ent Adviso ^ Personnel Board
^ Commun' Relations Board ^ Plannin Board*
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indust Counal
^ Desi n Review Board* ^ Public Safe Adviso Committee
^ Disabil' Access Committee ^ Safe Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Tran nder GLB ^ Sustainabili Committee
^ Golf Advi Committee ^ Trans arenc Reliabilit & Accountabili Committee "TRAC"
^ Health A Committee ^ Trans rtation and Parkin Committee
^ Health Facilities Autho ' Board ^ Vsitor and Convention Autho '
^ His nic Affairs Committee ^ Waterfront Protection Committee
^ Historic Preservation Board ^ Youth Center Adviso Board
*Board Required to File State Disclosure Form
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: , , `~7 t~
2. Present participation in Youth Center activities by your children Yes^ No ^. If yes, ple~i~~;l7i~h~ ~ rt`almes~ ~f ~ildren, their
ages, and which programs. List below:
Child's name: Age: Program: ~,_~„~ ~~[' 6QQZ
Child's name: Age: Program: -
Position:
~~
.Have you ever been convicted of a felony: Yes ^ or No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ^ or No R~ yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ^ or No ll~yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes ^ or No~lf yes; which ILoa~ ~~ ~. ~
~~r..l[]c. Io ~ ~ ~ ~. w-~ ~_~Q,b ~ Cif'
• What organizationsnin the Cityc~of~Miami Beach do~y_oIu- curr~e~ntly'hOold membership in? (~~~~ ~~ ~ ~~i`~' ~~
Name: n~ u fi~ l b(y )'- t rl c~ ~¢. ~c.r1~ I p ~ S~ UC~rC~ Title: ~
Name: •Aw- - ~ ~ ~ ~A ~ Tiptle: ~ >! ~. ~~,"~
• List all properties ownettdor have an interest in, Ic are orated within the City of Mi i Beac .
24 tl -l 1~lTYa r} P . /rhtQ _ Since. ~~
• I am now employed by the City of Miami Beach: Yes ^ or No~wnich 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):
The following irrfortnation is voluntary and is nekher part of your application nor has any bearing on your consideration for appointment. k is
being asked to comply with federal equal opportunky reporting requirements.
Gender: ^ Male [9"Female
Ethnic Origin: Check one only (1)
~Illhite (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-AmericanlBlack (Not of Hispanic Origin): All persons having origins in any of the Bladc racial groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
^ Asian or Pacfic Islander. All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Paafic Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain
ft CuRural ideMif~ation through tribal affiliation or community recognition.
Yes ^ or
Employment Status: Employed ^ Retired Homemakerf~ Other ^
NOTE: If appointed, you will be required to follow certain laws which apply to city boardlcommittee members.
These laws include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying aty personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the city (Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami
Beach City Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office,
from having any interest in or receiving any benefrt from Community Development Block Grant funds for either yourself ,
or those with whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk.
"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 Ci C de "Standards of Conduct for City Officers, Employees and Agency Members."
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Applicant's Signature '~~~ Date ' Name of Applicant (PLEASEQ INT) ~y T
Please attar~r a spy of your resume to this application C~'0 ldrno~n -S ~Z01,1 ~~ r1~y ~ I' y
NOTE: Applkations will remain on flls for a period of one (1) calendar year.
Received in the City Clerk's Office by
of Deputy Clerk
Date: ! /2009 Control No~~ Date