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Wendy S. UngerNAME: ~AIAMI BEACH V CITY OF MIAM! BEACH BOARD AND COMMITTEE APPLICATION FORM HOME ADDRESS: _ PHONE: ~.3 ~ ~~ Last Name ~ ~~ ~~~ No. I ~~L ~ Firs Name Mid le Initial ~a~ City State Zip Code ~~~ l (~~J1 ~~ ~~~ ~~©~fKill~td4~~r11g0° ' Home nn ~~,,~~ L' Wor~kn ~ ~~~'b,~/~~".+. = Email address ~ ~_ Business Name: ~ ~ ~v vl ] ~-6-i~ CGth~t~°~~ ~`~ Position: i~/l i5{,~ _~4f~~ Sz-~2~'~~~ r~'( ~--z~_ `~~ Address: ~ ~~ LEJ V v t 1"~~ I ~/ A- ~ ~-~`~, P'11 ~'(,( ~~~-~ ~~ 3 ~ ~ 3 No. Street City State Zip Code Professional License (describe) Expires: Attach a copy of the license 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 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 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 fiddle Beach} • f am applying for an appointment because I have special abilities, knowledge and experience. ease is elow: • Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No~' Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the Citv Clerk's Office. (Regular Boards of City) ^ Affordable Housin Adviso Committee ^Housin Authorit ^ Art in Public Places Committee ^ Loan Review Committee ^ Beautification Committee ^ Marine Author' ^ Board of Ad'ustment* ^ Miami Beach Commission for Women ^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council ^ Ca ital Im rovements Pro ects Oversi ht Committee ^ Miami Beach Sister Cities Pro ram ^ Committee on the Homeless ^ Normand Shores Local Government Nei h. im rovement ^ Committee for Quali Education in MB ^ Parks and Recreation Facilities Board ^ Communi Develo ment Adviso ^ Personnel Board ^ Communi Relations Board ^ Plannin Board' ^ Convention Center Adviso Board ^ Police Citizens Relations Committee ^ Debarment Committee ^ Production Indust Council ^ Desi n Review Board" ^ Public Safe Adviso Committee Disabili Access Committee ^ Safe Committee ^ Fine Arts Board ^ Sin le Famil Residential Review Panel ^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabilit Committee ^ Golf Advisor Committee ^ Trans aren Reliabili & Accountabilit Committee "TRAC" ^ Health Adviso Committee ^ Trans ortation and Parkin Committee ^ Health Facilities Authori Board ^ Visitor and Convention Authori ^ His anic 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: , 2. Present participation in Youth Center activities by your children Yes^ No ^. If ye pt~~$~ li5't~~fie~n~e(S-~~~our children, their ages, and which programs. List below: Child's name: Age: Progr~ ~ ~ ~~ ' - d~s 6Q~Q~ Child's name: Age: Program: 4 F:\CLEP.\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc •Have you ever been convicted of a felony: Yes - or No ~lf yes, please explain in detail: • Do you currently have a violations} 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~ If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes C or No~ If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: Title: 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 C, spouse ^, child r, brother C, or sister ^ who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): r - (~ -- The following information is voluntary and Is neither part of your application nor has any bearing on your consideration for appointment. It is being asked to comply with federal equal opportunity reporting requirements. Gender: ^ Male Ethnic Origin: Check one only (1) ~Whlte (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. I' ^ 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, far 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 Nod. Employment Status: Employe 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 directly 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 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 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, copies of these laws may be obtained from the City Clerk. "I hereby att the accuracy and truthfu ess o the application and have received, read and will abide by Chapter 2, i I VII - f he C Code "Standards of ndu for City Officers, Err/ployee and Agency Me " k. :, ~ ~ t A p a u Date Name of Applicant LEASE PRINT) t Please attach a cop of your resume to this application NOTE: Applications will remain on file for a period of one (1) calendar year. Received in the City Clerk's Office by : Date: _/ !2009 Control No. Date: ! !2009 Name of Deputy Clerk ---