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Ana B. Gomezm ni,la,r,,^,!BEACH SC)ARD AND COMMITTEE t,4PPLiCAiT10N F©RM NAME: ~_~~ Lact N~n,G (',Z Ftrst Name Middle Initial HOME ADDRESS:Ap~~~ ~ t{ ~- I ~ ,,,~ ~A ~ r ~,h ~i,4 1 Fl 331 House No./Street City PHONE: 30 ~, ~ I?~~ State Zip Code Home Work ~ 4 Q tYl ~ ~ rn Q Fax Email address ~ ~ ~ Business Name: ~--((SPfl ~I~ ~ ~ ('Ofi~ Position: C ,~ Al T 2 ( ~{ ~} ~ ~, ~ ~-~ Address: p I ` $ ~ No. street ` 33 J ~ t Professional License (describe) Ctty State Zip Code Expires: Attach a co py of the license Pursuant to Clty 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 ownershiprnterest 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 0 • 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: North Beach South Beach PP Y 9 • I am a I in fr~r an appointment because I have special abilities Middle Beach ,knowledge, experience. Please fist below: • Are you presently a registered lobbyist with the City of Miami Beach? Yes D or No ^ Please list your preferences in order of ranking [1] first choice [Z] second choice, and [3] third choice. Please note that onl choices will be observed b the Clt Clerk's Office, (Regular Boards of City) v three l31 ^ Affordable Housin Adviso Committee ^ Art in Public Places Committee ^ Beach Preservation Board ^ Beautification Committee ~ Board of AdiustmAr,t* ^ Committee ~ ~ommlttee on the Homeless ^ Committee for Quali Education in MB 0 Commurnty Development Advisory ^ Community Reiations Board ^ Convention Center Advisory Board ^ Debarment Committee ^ Design Review Board" ^ Dtsabill Access Committee ^ Fme Arts Board ^ Gay Business Development Ad H ^ Golf Adviso Committee ^ Health Advisory Committee ^ Health Factltttes Authorit Board D Hispanic Affairs Committee ^ Historic Preservation Board ^Housin Authori D Loan Review Committee ^ Marine Authori ^ Miami Beach Commission for Women ^ Miami Beach Guttural Arts Council Committee Miami Beach Sister Cities Pro ram D Normand Shores Local Gov't Nei h. I D Parks and Recreation Facilities Board ^ Personnel Board D Plannin Board* ^ Police Citizens Relations Committee D Production Indust Council D Public Safe Adviso Committee ^ Safe Committee ^ Sin le Famil Residential Review Panel ^ Sustainabili Committee ^ Trans arenc Reliabili & Accountabifit ^ Trans ortation and Parkin Committee 0 Visitor and Convention Authori ^ Youth Center Advisnr~ R„~~,~ Committee "TRAC" F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application 2 ~ g09 d Board Required to Flle 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 2: Years of Service: lease list the names of your children., their 2. Present participation in Youth Center activities by your children Yeses No ~. If yes, p ages, and which programs. List below: Age: Program: Child's name: Age: Program: Child's name: .Have you ever been convicted of a felony: Yes ~ or Nod tf 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's If yes, explain in detail • Are you currently serving on any City Baards or Committees: Yes D or No ^. If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Title: Name: Title: Name: • List all properties owned or have an interest in, which are located within the City of Miami Beach: • l am now employed by the City of Miami Beach: Yes ~ or No',~; Which department? • Pursuant to City Code Section 2-25 (b): Do you a de artment(s): spouse C, child G, brother C, or sister ~ who is employed by the City of Miami Beach? Check all that apply. Identify th p Gender: Male ^ Female Race: White Black ^ Ethnic Origin: Asian or Pacific Islander ^ African-American/Black a American Indian or Alaskan Native 0 Hispanic: ^ White -Not Hispanic Physically Challenged: Yes 0 or rv "{ hereby atte o the accuracy and truthfulness of the application and have received, read and wilt abide by Chapter 2, Article VII - City Code "Standards of Conduct for City Officers, Employees and Agency Members." 6 ~' ~ Name of Applicant (PLEASE ate Applicant' i nature PRINT) Employment Status: Employed~Retired D Home-maker ^ Other f ~-V Dat Received in City Clerk's Office by Name of Deputy Clerk '?// 0 ~~ Entered dy to Revised 09102 Document Control Number (Assigned by the City Clerk's Office) ~ _---- F:\CLER\~ALL\aFORMS\BOARD AND COMMITTEES\BC Applicotion 21309.doc