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Andrew A. FischerNAME: MIA.IV~.iBEACH r ~ s~,~-. CITY OF MIAMI BEACt"3 AND COMMITTEE APPLICATION FORM HOME ADDRESS PHONE: Hor Business Name: Last Name First Name «~S ~~ ff7~ ~~ Apt No. House No./Street Work Fax Position: I address Address: ~~S ~ / ~~ 1~',~,~ Fi~ ~2& ! f ~rn: ©°~.~ ~~.. 3313 ~ No. `` Street City State Zip Code Professional License (describe) "~'~1`~ ~ ~~ ~G~ 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 minimu//m of six months in a business established in the city. • Resident of Miami Beach for a minimum of six (6) months: Yes ^ or No~f • Demonstrate an ownership/interest in a business in Miami B h for a minimum of six (6) months: Yes~6 or No ^ • Are you a registered voter in Miami Beach: Yes ^ or No f • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: • 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 (31 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 Authori ^ 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 ommittee 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 ^ Communit 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 ^ Sustainabili Committee ^ Golf Advisor Committee ^ Trans arenc Reliabilit ~ Accountabilit Committee "TRAC" ^ Health Adviso Committee ^ Trans ortation and Parkin Committee ^ Health Facilities Authori Board ^ Visitor and Convention Authori ^ His anic Affairs Committee ^ Watertront Protection Committee istoric 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 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: Middle Initial City ~ State Zip Code F\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc i/ .Have you ever been convicted of a felony: Yes _ or No'te' If yes, please explain in detail: • Do yo currently have a violations of City of Miami Beach codes: Yes ~r No G. If yes, plea~e explain in detail: / r' 1 C ~ . Do y~ currently owe the City of Miami Beach any money: Ye///syyy~ or No !^ yes, epxpl in in detail • Are you currently serving on any City Boards or Committees: Yes C or No~f yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Title: Name: Title: all properties owned or have an interest in, which are located within the City of . I am now employed by the City of Miami Beach: Yes ^ or No'~!G-hich department? ~C, c~-c. • Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse G, child C, brother ^, or sister ^ who is employed by the City of Miami Bach? 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 considerat[on for appointment. It is being asked to co y with federal equal opportunity reporting requirements. Gender: Male ^ Female Check one only (1) CwWhite (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. ^ African-AmericanlBlack (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. Challensted: Yes ~ or Employment Status: Employed b/ Retired ^ Homemaker ^ Other ^ NOTE: If appointed, you will be required to follow certain laws which apply to city boardlcommittee members. These Paws 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 boardlcommittee 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 here ttes tAe acc cy and truthfulness of the application and have received, read and will abide by Chapter 2, Arti II - the Ci die "Standards of Conduct for City Officers, Employees and Agency Members." ~. p cant's Signature -~ tie Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application NOTE: Applications will rema//~~ on file for a period of one (1) calendar year. Received in the City Clerk's Office by : /G~ Date: _/ 12009 Control N~_ Date: ~~~l2009 Name of Deoutv Clerk ,~.-~ `. ~~~