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Frank Kruszewski Board Application 11/9/09~A NAME: ~'~ ~ ~~ :~ ;' ~ ,_ ~~ s r Last Name ~t rJ / First Name } !Middle Initial HQME ADDRESS; .~~ ~- f ~tltG~ t"'ttX ~2 r~caY ~Y" /~_1 "f ~ ~~~.~~~ Apt No. House No.JStreet City j State Zip Gode PHt?NE; ~ ~z ~r-~., r ~ U S'~ ~tj"G 1 ~ I 3G S' ~ ~ / ~-'2 6i'° ~SCd~i~ ~ 1C~~u + w rcr ~ -~-- Home Work Fax Email address Business Name: Position; Address: No. Stree City State Zip Gade Professional License (describe} ~- C' ~ ~ ~ Expires: 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 fuit711ed in the fallowing ways: a) an individual shall have been a resident of the city for a minimum of six months; ar b) an individual shall demonstrate awnershipfinterest 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 r No + Demonstrate an ownershipfinterest in abusiness in Mi ~ Beach for a minimum of six (6) months: Yes [~-oF`~lo ^ + Are you a registered voter in Miami Beach: Yes r No + {Please circle one): f am now a resident of: North Beach South Beach fiddle Bea + I am applying far an appointment because 1 have special abilities, knowledge and experien 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 [i] first choice [2] second choice, and [3] third choice. Please note that only three {3l choices will be observed by the City Clerk's ©ffice. {Regular Boards of City) ^ Affordable Housin Adviso Gommittee ^Housin Authori ^ Art in Public Places Gommittee ^ Loan Review Committee ^ Beautification Gommittee ^ Marine Authorit ^ Board of Ad'ustment* ^ Miami Beach Commission for Women ^ Bud et Adviso Gommittee ^ Miami Beach Guttural Arts Council ^ Ga ital Im rovernents Pro'eets Oversi ht Committee ^ Miami Beach Sister Gibes Pra ram ^ Gommittee on the Homeless ^ Normand Shares Local Government Nei h. Im rovement ^ Gomrni#tee for Quali Education in MB ^ Gommunit Devela men# Adv'ssa ^ Parks and Recxeation Facilities Board ^ Personnel Baard ^ Gommunit Relations Baard Ptannin Board" ^ Convention Center Adviso Board Police Citizens Relations Gommittee ^ Debarment Gammittee ^ Production Indust Gauncil ^ Desi n Review Board* ^ Public Safet Adviso Gommittee ^ Disabili Access Committee '~~I ^ Fine Arts Baard ^ Safe Gammittee ^ Sin le Famil Residential Review Panel 0 Ga ,Lesbian, Bisexual and Trans ender GLB ^ Sustainabilit Committee ^ Golf Adviso Gommittee ^ Trans arenc Reliabil` & Accountabili Gommittee "TRAG" ~ ^ Health Adviso Gammittee ^ Trans artation and Parkin Committee ^ Health Facilities Authari Board ^ Visitor and Ganvention Authori ^ His anic Affairs Gammittee ^ Waterfront Protection Gommittee ^ Historic Preservation Board ^ Youth Genter Advisa Baard *Board Required to File State Disclosure Form Nate: 1f applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Gen r 1. Past service on the Youth Genter Advisory Board: Yes ^ No ^ Years of Service: 2. Present partiapation in Youth Genter activities by your children Yes^ No ^. If yes, please list the ames of your children, their ages, and which programs. List below: Child's name: Age: Program: Child's name: Age: Program: .. - - r ,. _ ..~, f~~~t~'~~~:~Ii~~S:~.~ _,. shave you ever been convicted of a felony: Yes ~ ar No~~.-lfyes, please explain in detail: s Do you currently have a violation{s) of City of Miami Beach codes: Yes ~ or N~~[;,'kfyes, please explain in detail: s Da you currently owe the City of Miami Beach any money: Yes ~ or No f yes, explain in detail s Rre you currently serving on any City Boards or Committees: Yes or No ~. If yes; which board? ~1 t s What organizations in the City of Miami Beach da y11ou currently hold membership in? Name: ~cr nr d r , bU ~ ~ ~ t.~ ~ ~ ~t ~- c~ ~a Title: ~ u r Name: Title: s List all properties owned or have an interest in, which are located within the City of Miami Beach: s I am now employed by the City of Miami Beach: Yes ~ or Nn ich department? s Pursuant to Gity Gode Section 2-~5 {b): Da you have a parent c, spouse ~, City of Miami Beach? Check all that apply. Identify the department{s}: 1 1/ ^, brother ~, ar sister ~ who is employed by the The following information is voluntary and is neither part of your application nor~ias any bearing an your consideration far appointment. It is being asked to comply with federal equal opportunity reporting requirements. Gender: ^ ale ^ Female Ethn~rigin: Check one only (Nat 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): Ali persons having origins in any of the Black racial groups of Africa. ^ Hispanic; Ali persons of Mexican, Puerto Rican, Cuban, Central or Svuth 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 Nar#h America, and who maintain Cultural identification #hrough tribal affiliation yr mmunity recognition. Physically Ghallenc~ed: Yes C~ or M~~ Employment Status: Employed l~./ Retired ^ Homemaker ^ ©ther ^ MOTE: 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 ar indirectly lobbying city personnel {Miami Beach City Code section 2-459}. o Prohibition from contracting with the city (Miami-Dade County Cade 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 Cade 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 ar receiving any benefit from Community Development Black Grant funds far either yourself , ar those with wham you have business or immediate family ties (CFR 570.fi11). Upon request, copies of these taws may be obtained from the City Clerk. "1 her y hest the ccuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Arti - e Gi Code `"Standard of onduct for City Officers, Employees a d Agency Members." _ / ~~Jt~t u > ~ ~ r Ap a i atur Date Name of Applicant (PI-EASE PRINT) Please alto a copy of your resume to this application NOTE: Applications will remain on file for a period of one {1}calendar year. Reoeived in the City Clerk's Office by , Gate: _,_.1 !2009 Control No. Date: ~/ /2009 Name of Deputy Clerk