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Pursuant to City Code section 2-22(4) a and b: Members of dies, boards, and committees shall be affiliated with the city; this
requirement shall be fuffilled 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 i iami Beach for a minimum of six (6) months: Yes D or No u
• Are you a registered voter in Miami Beach: Yes or No ^
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I am applying for an appointment because 1 have special abilities, kno and experience. Please list below:
• Are you presently a registered lobbyist wdh the City of Miami Beach? Yes ~ or No
Please list your preferences in order of ranking [1] first choice [2] second choice, and [S] third choice. Please note that only three (31
choices will be observed by the City Clerk's Office (Regular Boards of City)
u Affordable Housin Advisory Committee ^ Historic Preservation Board
^ Art in Public Places Committee ^ Housing Authority
^ Beach Preservation Board D Loan Review Committee
^ Beautycation Committee D Marine Authori c=
^ Board of Ad~ustment' ^ Miami Beach Commission for Women `a
D Bud et Adviso Committee ^ Miami Beach Cultural Arts Council ;
^ Ca ital Im rovements Pro ects Oversi ht Committee ^ Miami Beach Sister Cities Pro ram r'°` r' .
0 Committee on the Homeless ^ Normand Shores Local Gov't Nei h. Im ro ~ en
^ Committee for Quality Education in MB ^ Parks and Recreation Facilities Board =~-
^ Community Development Advisory ^ Personnel Board c,f; 'Z3 °'`
^ Communi Relations Board ^ Plannin Board' ~~
^ Convention Center Adviso Board D Police Citizens Relations Committee -,-
^ Debarment Committee ^ Production Indust Council O
D Design Review Board' ^ Public Safety Adviso Committee
D Disabili Access Committee ^ Safe Committee
^ Fine Arts Board ^ Sin le Fami Residential Review Panel
a Business Develo ment Ad Hoc ^ Sustainability Committee
^ Gay, Lesbian, Bisexual and Trans ender (GLBT) ^ Transparency Reliabil~ 8 Accountabili Committee "TRAC"
D Golf Adviso Committee ^ Trans rtation and Parkin Committee
^ Heatth Adviso Committee ^ Visitor and Convention Authori
D Health Facilities Authority Board ^ Youth Center Advisory Board
^ Hispanic Affairs Committee
Board Re wired 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:
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:
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.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;~Jf yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes J or No~ If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes
No -. If yeTs; wlhich board?
• What organizations in the City of Miami Beach do you currently hold me~bership i/n~?
Name: ~ ~ Title: V/6!~ (..~'l/L~
Name: Title:
• List all properties owned or have an interest in, which are loei~within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes J or N~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):
The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. k is
being asked to comply with federal equal opportunity reporting requirements.
Gender: ^ Male ^ Female
Ethnic Origin: Check one only (1)
^ White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-American/Black (Not of Hispanic Origin): All persons having origins in any of the Black 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 Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Pacific 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
Cultural identification through tribal affiliation or community recognition.
Physically Challenged: Yes ~ or No^.
Employment Status: Employed ~ Retired ^ Homemaker ^ Other ^
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to, the following:
o Prohibition from directy or indirectly lobbying city 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 boardlcommittee you have served on for period of one year after leaving office (Miami
Beach City Code section 2-26).
o Requirement to disGose 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 benefit 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, co~jrs.Pf these laws may be obtained from the City Clerk.
t accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
- Code "Standards of Conduct for City Officers, Employees and Agency Members."
Signature Date Name of Applicant (PLEASE PRINT)
Phase attach a copy of your resume to this
NoTe: AAaa
will remain on file for a period of one t1) calendar year.
Received in the City Clerk's Office by : _ ~ ~~yL.Q ~~~ Dat~/ 09 Control No. Date: _/ /2009