Merle Weiss 11/19/2009m !~~~ I >~>>f~~i BE~C ~
NAME:
HOME ADDRESS:
Last N
'„ n t~. Middle Initial I
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City tat~\ Zip Code I
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1 n Email address I f
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PHONE: ~ ~ ~ ` ~~
Home
Business Name:
Address:
No.
Professional License (describe) _
City State Zip Code
_ Expires: - Attach a copy of the li
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; tl
requirement shall be fulfilled in the following ways: a) an individual shall have' been a resident of the city for a minimum of
months; or b) an individual shall demonstrate ownership/interest fora imum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) mon s: Yes or No ^ /
• Demonstrate an ownership/interest in a business in tame Beach for a minimum of six (6) months: Yes ^ or No `0'
. Are you a registered voter in Miami Beach: Yes r No ^
• (Please circle one): I am now a resident of: North Beac South Beac I~liddle Beach
• I am applying for an appointment because I have special abil' ' e and experie Please list below:
r
• 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 Clty Clerk's Office, (Regular Boards of City) I
^ Affordable Housin Adviso Committee 0 Housin Autho ' I
^ Art in Public Places Committee ^ Loan Review Committee I
^ Beautification Committee ^ Marine Autho ' I
^ Board of Ad'ustment* ^ Miami Beach Commission for Women I
^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council I
^ Ca 'ttal Im rovemerrts Pro acts Oversi ht Committee Miami Beach Sister Cities P ram ~"~ rv I
^ Committee on the Homeless ^ Normand Shores Local Government Nei h. ro ant I
^ Committee for Qual' Education in MB ^ Parks and Recreation Facilities Board ~c I
^ Commun' Develo ment Adviso ^ Personnel Board ;= .~ I
^Commun Relations Board ^ Plannin Board* ~ - ` ' I
^ Convention Center Adviso Board ^ Police Citizens Relations Committee ~ ~ I
^ Debarment Committee ^ Production Indus Council vi ~
^ Desi n Review Boarcf* ^ Public Safe Adviso Committee a I
^ Disabil' Access Committee ^ Safe Committee --, I
^ Fine Arts Board ^ Sin le Famil Residential Review Panel=; ~- I
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabil' Committee '-'-'
^ Golf Adviso Committee ^ Trans wren Reliabil' & Accountabili Committee "TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee I
^ Health Facilities Autho ' Board ^ Visitor and Convention Autho ' I
^ His anic Affairs Committee ^ Waterfront Protection Committee I
^ Historic Preservation Board ^ Youth Center Adviso Board I
I
"Board Required to Flle State Disclosure Form I
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 G. If yes, please list the names of your children, the
ages, and which programs. List below:
Child's name: Age: Program:
Child's name:
Age: Program:
F:\CLEP.\$ALL\oFORMS\BC)ARD AND COMMITTEES\BC Application0626~9 NEW.doc
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CfTY OF MIAM{ BEAC
,R~~D~A~1~ COMMITTEE ~4PPLICATION FORI
rst Name
Position:
r
.Have you ever been convicted of a felony: Yes - r N If yes. please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes =. r No . If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes D ~No~. If yes, explain in detail
• Are you currently serving on any City Boards or Co mitte Y
~~ ~ ` Gu~~U ~~'
(~ or No =. If yes; v,(h h board?
U1~ In ~
• What or/g~anizat/ion In the ity of Miami Beach do you currently hold membership in?
Name: 7 ~~I • ~~~-~~~ Title: ~~,~~~~~
Name: Title:
• List ail~ro~rties ~ ed or ve~a~re~st in, ich are located within the City of Miami Beach:
It 1 ~ i/
• I am now employed by the City of Miami Beach: Yes ^ or N. Which department?
e Pursuant to City Code Section 2-25 (b): Do you have a parent ~, spouse ^, child D, brother D, or sister D who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
The following information is voluntary and is Walther part of your appllcatton nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Gentler: 0 Male ~ Female
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 Originj: All persons having origins in any of the Black racial groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Cerrtral 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 (stands and Somoa.
^ Amercan Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who mairrtain
Cultural identfftcation through tribal aftiliation ar community recognition.
Yes D or Noq~
Employment Status: Employed ^ Retired ^ Homemaker ^ Other ^
NOTE: If appointed, you will be required to follow certain laws which apply to city boardlcommittse 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 attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Artic of the Clty Code "S ndards of Conduct for City Officers, Em loyees and A cy Mem "
_ ~~~~~" w~`~ SS
Applicant's gnature Date Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE: Applications wilt remain file f r a period of one (1) calendar year. /
Received in the City Clerk's Office by : - Date: _/ /2009 Control No„-- ~~ Date: ~ /200 v~
Name of Deputy C rk