Sheila Duffy-Lehrman~ M ~ AM I B EAC H CITY ®F MIAMI BEACH
B®ARDS AND COMMITTEE APPLICATION F®RM
NAME: V
ast N
HOME ADDRESS: ~,Q
No.
PHONE ~~'L3~ si3c
Home
Business Name: I ~LN%I L
Address: (~ ~7 IVG ~
r
Professional License (describe)
-`~ -
Work
First Name
Street
Street
WIC ~t 3~3I~
City State Zip Code
Email
7 Y"a
1.~/V.~
ly State Zip 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 aty; this
requirement shall be fulfilled in~the following ways: a) an individual shall have been a resident of the aty for a minimum of six
months; or b) an individual shall demonstrate ownershiplnterest for a minimum of sa months in a business established in the aty.
• Resident of Miami Beach for a minimum of six (6) month :1 es or No
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes q~
• Are you a registered voter in Miami Beac Yes or No
• (Please check one): I am now a resident of: North Beach South Beach Middle Beach
,• I a'm-~,a~p/plying for~ann,,a,,p~,p/ointment because I have special abilities, knowledge, ex~p"er~ie~n~c~e. Please list below:
1U~u'~:! I`j1Y\OJ~' I 1 ~-~It~Gi '~ / b U51~IL~S ~1n~1~~ ~ ~ ~tirf 1~fi~tLt.i/l(M.YiK~' , I/~~, ~ G....~t r
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 City Clerk's Office. (Regular Boards of City)
Art in Public Places Committee
! Beach Preservation Board
Beautification Committee
Board of Adjustment*
Budget Advisory Committee
Committee on Homeless
Committee for Quality Education in MB
Community Development Advisory*
~~Community Relations Board
( '!, convention Center Advisory Board
Debarment Committee
Design Review Board*
Disability Access Committee
Fine Arts Board
Golf Advisory Committee
Health Advisory Committee
Health Facilities Authority Board
Hispanic Affairs Committee
Historic Preservation Board*
* Board Required to File State Disclosure form
_~-f_f,~
Fax
Housing Authority*
Loan Review Committee*
Mayor's Green Ad-Hoc Committee
Marine Authority*
Miami Beach Cultural Arts Council
Miami Beach Commission on Stat of Women
Miami Beach Florida Sister Citie
Normandy Shores Local o e .Improvement
Oversight Committee for General Obligation Bond
Parks and Recreation Facilities Board
Personnel Board*
Planning Board*
Police Citizens Relations Committee
Production Industry Council
Public Safety Advisory Committee
Safety Committee
Transportation and Parking Com ee
visitor and Convention Authori
ouY h Center Advisory card
~.-';
Si'
1
C:\Documents and Settings\cc~npurbm\Local Settings\Temporary Internet Files\OLK1C5\I3C Application Revised July 18 2007.doc
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:
.Have you ever been convicted of a felony: Yes r No 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 No If yes, explain in detail
~,^ Are you currently serving on any City Boards or Committees ~ or No If yes; which board?
1 - CCU I
.What organizations in the City of Miami Beach do you currently hold membe hip in? U
Name: ~~~~ ~ Title:
Name:
Title:
• L~'st all properties owned or have an interest in, which are located within the City of Miami Beach:
• 1 am now employed by the City of Miami Beach: Yes o No .Which department'?
• Pursuant to City Code Section 2-25 (b): Do you have a parent spouse Id ,brother , or sister who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ~ ~ ~(~ _
This section is "not required" but desired: Age: ~Q years old Gender. Male Female
Ethnic Origin (Check one)
lte African-American/Black Hispanic: Asian or Pacific Islander American Indian or Alaskan Native
mployment Status: Employed Retired Home-maker Other
"I hereb attest to the accuracy and tnrthfulness of the application and have received, read and will abide by Chapter 2,
' e I - of the i od "Stardonduct for City Officers, Employees and Agency Members."
Name of Appl~nt (PLEASE PRINT)
Please-atl~ch a copy of your resume to this application
NOTE: Applications will remain on file for a period of one (1) calendar year.
Received in City Clerk's Office by ~'` ~ f ~ 7 Date
N me of Deputy Clerk 1
Document Control Number (Assigned by the City Clerk's Office) J~~~ Entered By ~~~~ Date ~ ~ 1 r v
T Revised 1/2 7 jo
2 ~,,%.
C:~Documents and SettingslcompurbmlLocal SettingslTemporary Internet Files\OLK1C5\BC Application Revised July 18 2007.doc