Jay ParkerCITY OF MIAMI BEACH BOARDS AND COMMITTEE
APPLICATION FORM
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; tt
requirement shall be fulfilled in the folbwing ways: a) an individual shalt have been a resident of the city for a minimum of six months; or
an individual shall demonstrate ownership/Interest for a minimum of six months in a business estab{ished in the city,
Resident of Miami Beach for a minimum of stx (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 [ ]
I am applying for a Board appointment because I have special abilities, knowledge, experience: Yes [ ]
My special abilities, knowledge, or experience is:
Are you a registered v ter in Miami Beach: Yes [ ] or No ]
NAME: ~A'-~~~ _- - ~~
Last Name First Name Middle Initial
Home 3r11o° fK£~~D~~ ~ _. /`ll~~li ~C1.1 ~~ S3l ~~
Address: No. Street City State Zip Code
Phone: 3° ~ 3 23 ~SS~'r~~G~'.~Z`l ~' .~ 67Z6E3z ~°7~ ~~~c~~~~4l;Ca~l
Home Work Fax Email address
I am now a resident of: North Beach [ ]South Beach [ ]Middle Beach
Business Name:
Address:
No.
Applicant's Position:
Street
Gty
[ ]Owner [ ]Stockholder/Shareholder [ ]Corporate Officer [ ]Other Explain:
State Zip Code
Professional License (describe): Expires;
Attach a c»py ofthe /icense /iste+d above.
1. Have you ever been convicted of a felony: Yes [ ] or No ~es, please explain in detail:
2. Do you currently have a violation(s) of Gty of Miami Beach codes: Yes [ ] or No [-]~"I~yes, please explain in detail:
3. Do you currently owe the City of Miami Beach any money: Yes [ ] or No [~-~j~
If yes, explain in detail:
4. Are you currently serving on any Gty Bo~s o~~:o ittees: Yes ~ No [
If yes; which board? ~G ~ _~
What organizations in the Gty of Miami Beach do you currently hold membership in?
Name: 1 Title:
Name: Title:
List all properties owned or have an interest in, which are located within the Gty of Miami Beach:
I am now employed by the City of -Miami Beach: Yes [ ] or No [ If yes, wh'~ch departrnent.
Pursuant ~ City Code Section 2-25 (b): loo you have a parent [ ], spouse [ ], child [ ], brother [ ], or sister [ ]who
Is employed by the Gty of Miami Beach? Check ail that apply. Identify the department(s):
Please list your preferences in order of ranking [i] first choice [2] second choice, and [3] third choice. P{ease note th
only 3.,choices will be observed by the Gity Clerk's Office.
(R ar Boards of City) (*Board Required to Fife State Disclosure form)
[ ]Art in Public Places [ ]Marine Authority*
[ ]Audit Committee [ ]Miami Beach Culture! Arts Council
[ ]barrier Free Environment Committee [ ]Miami Beach Commission on Status of Women
[ ] ach Preservation Board [ )Miami Beach Florida Sister Cfies
[ autificatbn Committee [ ]Normandy Shores Local Gov't Neighborhood Improvement
Board of Adjustment (Flood Mgmt.)* [ ]North Beach Youth Center Oversight Committee
[ )Budget Advisory Committee [ ]Nuisance Abatement Board*
[ ]Committee on Homeless [ ]Oversight Committee for General Obligation Bond
[ ]Committee for Quality Education in MB [ ]Parks and Recreation Facilities Board
[ J Community Development Advisory* [ ]Personnel Board*
[ ]Community Relations Board [ ]Planning Board*
[ ] Co ntion Center Advisory Board [ ]Ponce Citizens Relations Committee
[ ] nv lion Center Capita! Projects Oversight [ ]Production Industry Council
[ rment Committee [ ]Public Safety Advisory Committee
[ esign Review Board* [ ]Safety Committee
Fine Arts Board [ ]Transportation and Parking Board
]Golf Advisory Committee [ ]Visitor and Convention Authority*
[ ]Heal Advisory Committee [ ]Youth Center Advisory Board
[ ] H th Facilities Authority
[ ] ispanic Affairs Committee
[ ~ Historic Preservation Board*
[ ]Housing Authority*
[ ]Loan Review Committee*
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 [~J"(Years of Service [ ]
2. Present participation in Youth Center activities by your children Yes [ ] No [ ]. If yes, please list the names of you
children, their ages, and which programs. List below.
Child's name: Age: Program:
Child's name: Age: Program:
This section is "not required" but desired Age: [ ] Gender: M [ ] or F [ ]
Ethnic Origin (Check one)
White [ ] African-American/Black [ ] Hispanic: [ ]
Asian or Pacific Islander [ ]America Indian or Alaskan Native [ ]
Employment Status: Employed [ Retired [ ]Home-maker [ ]Other [
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
rl rs." 31,6 ~ ~ ~~t26CG ~~.
~ ~_
plica Signature Date Name of Applicant (PLEASE PRINT)
Attachment: Please attach a copy of your resume to your application.
NOTE: Applications will remain on file fora rind of one (1) calendar year.
Received in City Gerk's Office ~ ~ ~p by ~~¢1.-- Gerk
Document Control Number (Assigned by the Gty Gerk's Office) Rev #7- 01/08/04