Juan A. Martinez/ Y ~~~~~)
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No. First Na d7
PHONE: ~r ~ d-~ ~ •C ~I me /7 .
3 _ Street ~ ~Ye
Horne f/~ (~ (' ~~'~ Middle Initial
Business Na work 7 City ~~
me: ~~~ State ~
gddress: ~/ Fax ZtP Code
~~' o .rG'.y7 Email
T- address
Prole N Position;
ssional License ~~
(describe Str c ,'
eet ~,/ /,I ~~
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Pursuant to Ci City
re4uireme ~ Code section 2- ~.~~~
months; o nt shall be fulfilled in 22(q) a and b: State
Expires: ZiP Code
b) an individual sh the folio Members of a
all demonst wing ways: a) an indiv dua sh b°ards, and co ~~rac><j a ca
• Resident of ate ownership/fntere p~ crime r"er15e
Miamf Beach for st for all have been -nmittees shall be
a -ninl a min-mu a resident affiliated
• Demonstrate mum of six (6 m of six months in a b °f the cit with the cit
an ownership/fntere ~ months: usiness y fOf a mini y' this
st fn a b Yes~or No D established in the °f six
• Are you a registere usiness in Mia city,
d voter ' mi Beach for
• Ple rn Miami Beach: Y a n,fni,,,
( ase c-~ one : esor No ~ um of six (6
~ I am no )months: Yes ^ or No ~
w a resident of•
• I am applying for an _ ~_.__.._.,,,.
appointment bec North Beach ,~-...,....~.._. ----
Please list ause - have South Bead)/`'
choices Y°ur prefe special abflitie~~no __..~' Midd-e Be
wilt be rences in order o f Wled ach
°bseryed b rankin ge. experienCe. pie
~ Affor the Ci Clerk's (~] first choice (y] seco ase list below:
dable Housin Offce• (Re
~ Art in Public P Adviso 9ular Boards d choice, and (3) third
i Beach Pres laces Co COmmittee of City) choi
-r-mittee ~' Please note
Beautific a Co1On Board ~ Health F that onl three
ation acilities
B-~dofA~r;,..,a_ mmrttee H;~.,__. Aut-,,,_:.. _ 3
C Ca ital Irn rove Co-nmittE
0 Committee meets Ove
^ Committee for Homeless
~ COmmunit Qualit Educ
~ COmmunit Re1afi!o meet Ar
C°nvenfion Ce ns Board
Cultural q~s rater gdviso
Nei hborhood ~
Debarment Committee
~esf n Review B
>isabilft gcCe °ard
ine Arts Board s Committee
a Business Dev
~If gdvisor Co elo meet Ad
een qd mmfttee
-~_Hoc c,,....~...
.,.. ~, ~ ranee ... ~ m[ee
Adviso Co raps arenc
mmittee Reliabilit &
d Required to Fpe state O Trans ortation and P
Disclosure form ~ Visitor and arkinc
~ Youth Convention Aut
~~~At.LtB Center gdvfso Boa
~`~ APplicationyg~~ ~pPtication RaviseU OS9908.q
oc ~
Board
~ J'~
~Y
v rvna
~ M~~ mt Beach
-~~~~~an° Shores
~ P~and RA....,._.
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Cen
~. fast service on the Youth Center Adviso Board: Yes ^ ter.
2. Present participation in Youth Center activities b N0 ^ Years of Service: _
ages, and which programs. List below: Y Your children Yeses No ^. If yes, please list the names of your children, their
Child's name: ~_
Child's name:
Age: _ Program:
Age: _____ Program:
•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 . If yes, please ex
plain m detail:
• Do you currently owe the City of Miami Beach any money: Yes ^ or No ~ . If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes ^ or No~lf yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Title:
Name:
Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes ~ or No[~Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spllouse ^, child ^, brother ^, or sister ^ who is em to ed
City of Miami Beach? Check all that apply. Identify the department(s):
P Y by the
This section is "not required" but desired: Age: ~ ears old
Ethnic Origin (Check one) Y Gender: Male Female ^
White ^Rfrican-American/Black ^ Hispanic: ~i'Asian or Pacific Islander ^ American Indian or Alaskan Native ^
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Cha ter 2
Article VII - of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
licant's
07/7!
Date
~~~
~~ease 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 Retired ^ Home-maker n ntl,A~ n
Received in City Clerk's Office by
Name of Applicant (PLEASE PRINT)
Name of Deputy Clerk
Document Control Number (Assigned by the City Clerk's Office
Entered
Date ~~~ ~~~~
Revised 04/18IOg LH
F:ICLERt~ALL1B&C Appiicaiior~AB&C hppiication Reviseu L'519~J&.doc