Michael I. Bernstein B&C Application~~~/ ~ I ,r~\~`~' ~ ~ ~~C ~ CfTY OF MIAMI BEACH
BOARD AND COMMfTTEE APPLICATION FORM
NAME: ~~5~1i/ 'M~ C'~7_' ~
Last Name First Name Middle Initial
HOME ADDRESS: 4D Sbb ~ Cc~U-l~s ~~t~y y~ /v~~ / 2~g-c.~i ~L ! 33t y ~
Apt No. House No./Street City State ~ Zip Code
PHONE: 3p5-6~~- ~O~ ( ?,OJ~~t' ~~y .3~5'~2- x/5"32 Mtb OQ I Q.~,i~.crnall.ro~
Home Work Fax Email address
Business Name: M 1 C~'A~'1-- S P~~Rr~7~r~ ~ ~lq
Address: Ib$'~ ~-$f~D21.D r+Ra/ INl9`llf~ ~Yl~ /~ 1~}yh
No. Street
Position: P~C-rS ItD ~1V T '
B~teirt- F_ X313 ~
Professional License (describe)
try
Code
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 fora inimum 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 r rami Beach for a minimum of six (6} months: Yes for No ^
• Are you a registered voter in Miami Beach: Yes t~or No ^
. (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
.tam applying for an appointment because I have special abilities, knowledge and experience. ease rst below:
• Are you presently a registered lobbyist with the Ciry of Miami Beach? Yes ^ or No)s~~
Please fist your preferences in order of ranking [1] first choice [2J second choice, and [3] third choice. Please note that only three (3)
choices will be observed by the City Cleric's Office. (Regular Boards of Ciry)
D Affordable Housin Adviso Committee ^Housin Autho
^ Art in Public Pieces Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Autho
Board ofAd'ustment" 1 ^ Miami Beach Commission for Women
^ Bud t Adviso Committee ^ Miami Beach Guttural Arts Council
^ C Ital Im rovemerrts Pni ects Oversi ht Committee ^ Miami Beach Sister Cities Pro ram
^ Committee on the Homeless ^ Normand Shores Local Govemmerrt Nei h. Im rovement
^ Committee for Qual' Education in MB ^ Parks and Recreation Facilities Board
^ Commun' Develo ment Adviso ^ Personnel Boarti
^ Commun Relations Board Plannin Board• 3
^ Conventon Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production indu Council
Desi n Review Baard• Z ^ Public Sa Adviso Committee
^ Dtsabil' Access Committee ^ Safe Committee
^ Fine Arts Board ^ Sin le Famit Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabil' Committee
^ Golf Adviso Committee ^ Trans aren Reliabil' 8 Accountabil' Committee "TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Faalities Autho ' Board ^ Visitor and Convention Autho
^ His anic Affairs Committee ^ Waterfront Protection Committee
0 Historic Preservation Board ^ Youth Center Adviso Board
"Board Required to Flle State Disclosure Form
Note: tf applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center. ,
_~ (S.~,.J31~ .~lIS
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 C. tf yes, ~I sE~li~~he~ani~~$~e~r children, their
ages, and which programs. List below:
Child's name: Age:_ Program:
a~ ~
Child's name: Age: Program:
F:\CLEP.\$All\oFORMS\BOARD AND COMMITTEES\BC Appli~ation062604 NEW.do:
.Have you ever been convicted of z felony: Yes o No if yes.. please explain in detail:
• Do you currently have a violation(s) of City of•Miami Beach codes: Yes = c~No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ~_
If yes, explain in detail
• Are you currently serving on any City Boards or Committees ~ Yes~r No ._.. If yes; which board?
C!]~ G
• 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:
S6 6 0 G) u-1,/S PNI`~`E V t ~` t O M l ~1nr-1 I t3 iti~t-- 3 I ~-/ y
• I am now employed by the City of Miami Beach: Yes ^ or Nq~ l~llhich department
• Pursuant to City Code Section 2-25 (b): Do you have a parent 7, spouse r, child C, brother C, or sister ^ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ~ n
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: XLtO(ale ^ Female
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.
^ 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 mairrtain
Cultural identification through Mbal affiliation or community recognition.
Physically Challenged: Yes ^ or No
Employment Status: Empioyed,~' Retired ^ Homemaker ^ Other ^
NOTE: If appoittted, you will be required to follow certain laws which apply to city boardicommittee 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). i
Upon request, copies of these laws may be obtained from the City Clerk.
"I her est to the accu cy and truthfulness of the application and have received, read and will abide by Chapter 2,
A e VII of th CI C "S erds~~of Conduct for City Officers, Employees and Agency Members."
-ZlBlog Mlet+'~2 a
Appli is gnature Date Name of Applicant (PLEASE PRINT)
Please attach a copy 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 ~.~""'~''-~ ~~`"x'~~ Date _/ /Z009 Control No ~yDate`~~~ ~0~
Name of Deputy Clerk