Jessica A. JacobsNAME: _~-,L:a~1 ~~ ~
Last Name
HDME ADDRESS: .® /~
Apt No.~~H•ous+
PHONE: ~Z~Llt~ "' ~'C~>~7
Business Name o~~~ ~~ 1~rY~~~ ~
Address: ~ [~» ~'
CITY Or' MIAiJII BEACH
Rd AND COMM[TTEE tiPPLICATION FORM
l
No. Stree'f" -City lath .p C
Professional U~nse (describe) ~~~~ Expires: Attach a copy of the license
Pursuant m City Code action 2 22(4) a and 6: M~rtbers of agencies, boards, and carnmittees 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 dty for a minimum of six
months; or b) an individual shall demonstrate ownership/mfisrest for a minimum of six months in a business~edm the dty.
• Resident of Miami Beach for a minimum of six (6} months: Yes >B or No 0 ~ c,~ °;~
• Demonstrate an ownershiplinGerest in a business u' ~-M'raurri Beach for a minxnum of six (6} months: Yes D o``i No
• Are you a registered valet in Miami Beach: Yes t]'or No ^ ; ~ t"' ~ ~°~
. (Please !~ one): I am now a resident af: North Beach South Beach tddte Beachr°' ~"' i t
• I am applying for an appointment because I have spatial abr~i4 s, iowladge and experience. ~~ ~.~-
s.e:c_
• Ate you presently a re~6ered lobbyist witit fhe City of Miatrri Beach? Yes 0 or No 18/' crf ~ ~
G~ '~
Please fist your pn#erent~ m order of tanidrrg [1} first choice [2] second choice, and [3} third choice. Please node ftra~onfv three !81
choices will •be ofad by the City Clerk's Office. (t2egular Boards of City) T, W
^ Affordable Housin Ativiso Commitfase D Hous Autho
D Art In Public Places Cotnsnitfae D Loan~Revrew Cornmittiee
D Beautfficafion Committ®e D Marine path
D Board of tts#rnenC D Miami Beach Commission for Women
D B Commitlee 0 Miami B~ic~r Cultural Arts Cotn'rCil
D C f Ctunrrdtiee D Miarnf Beath Sister Cities
D Committee on the Homers D N Shores Local Govertunerrt . im nt
D Committ3se for Education in MB D Parks and Recreation Fadtlties Boatd
D Commun Devei ant Advfso D Personnel Board
^ Comma Re~tiorrs Board D p Bpab•
D Convention Center Board f'efroe Ctt¢ens Retation5 Commitfas
D Debuarmerrt Committee D Production tnd {council
D !lest Review Board" Public. Gommitbae
D Disabii' Atx~ss Committee D Committee
D Fine Arts Board D Si Farm Resberfial Rev~w Panel
D G ,Lesbian. Bisexual and Tra nder G D Sustcrinabr Commitl~
D Goff ~ Con~~ D T 8~ Ali' Cmttmttloee "TRAC"
^ Health Adv~o Committee ^ T 'nand Paridn Ctmrmittee
D Health Faq'litres Autho Board 0 Yrsibr and Convention Aurtho '
D His nic Affairs Committee ^ Watefiont Protection Committee
Historic Preservation Board D Youth Center Board
Board 1Re aired to File State Disclosure Form
Note: ff applying for Youth Advisory Board, plea irrdieatie your affiCratiorr with the Stitt fialrow Youth Gender:
1. Past setvl~ on the Youth Carrier Advisory Board: Yes D No ears of ServioE- ~ ~ `
2. Present Pertiapation in Youth Center at~vities by your children Yes_t No ~ yes, please l' ~~~~ o~ Io~~diild' ~Z their
ages, and which programs. List beirnir. y
Child's name: ~: Pn~gram: _ (~ ,~ ~,~ ; ~ ~ ~ ~}
Child's name: Age: Program: ~ ~7
F:~=LEP\SALL~oFORMS\BOARD AND CDMMrrTFt:S~BC Appiicotion062609 N=W.doc
.!-lave you ever been convicted ~f 2 felony Yes : o' No/i` yes. pfeasp explain in detail:
,.-_
. Do you currently have a violation(s) of City of Miami Beach codes: Yes =. or No ~tf yes, please explain in detail:
. Do you currently owe the City of M'lami Beach any money: Yes ~ or No -. If yes, explain in detail
. Are you currently serving on any City Boards or Committees: Yes " or No -.. If yes; whist, board?
i
• What organizations in the City of Miami Beach do you currently hold membership in?
Title:
Name:
Title:
Name:
..List all properties owned or have an interest in, which are located within the City of Miami Beach:
. I am now ernpbyed by the City of Miami Beach: Yee ~~ or Nt~G' wntcn peparui~~c~I.
• Pursl~irrt to City Cone Section 2-25 (b): Do you have a parent C, spot~e G, chid G, broA~r L, or smiler 0 who is employed by the
City of Miami Beach? Check all that appry. Identify the department(s):
of our application nor has enY bearing on yow eonsidseatfon for appointment. It is
The following gt;formatlon is roluritary and k riettlter part y
being asked to comply with fed~ere~~l equal oppo-lunltY n~oiitng re~e~~•
Gender: 0 Maie p~emate
_E_th//nic Origin: Check one only (1) ~ r~ Nortlt Atr~ ~ ~ Mtn Eartt.
+XtNtif~ (Not of FiiBperdC Origin): AH persons twiiing °n8~ in ~ Of the original peoples
^ Africar--AmerleaNBiack (Not of HdC OriBltt): AQ p~eesons having origir~ 1^ ~Y of ttte tiladc rectal l of Airiw.
^ Fliapariie: Ag petty of ' PI!!nW ~-, Cuban. Gentrai or Soulh Arr-etlgn. or other Spanish allture or origlri, regardless of race.
D Asian or Pa~eific tsbintier: Ali persons tlalf~ origins in ahY of the origrtmi peoples of the Far ~ Southe$st Asia. the Iridiari ~, on
the Pacific tsiands. This area hiChtdes, for . Ctdra, trtda, ,fepari, Korea, the Pk grid Sanoa.
^ Atrrecicsr- imlimi or Alii~can NetHre: Ag pew having o~ in arN of the origiial peoples of NorB~i America. and who
Culbaal > trm~ i °r oonanWdly reii-
Yee n nr Iderl
Empbymerrt Status: Employed ~ Retired D liomerrlaker O Other O
NGTE: if app, Y~ tergl hie requhed to fol~ii- ca3rlair- taws which apply bo dtY ba~aitdicortttetitise tnemoees•
These laws lnciutt~, but are cot ihrtibad to, 7>~ fo1~fi-g:
o prohibition from direc~ty or irtdirec~ty lobbying ~Y p~onnel (Miami Beach City Code section 2-459).
o Prohibition from corrtractin9 wftti.fhe ~!' (Miami-Dade County Code section 2-11.1)_ ape (Miami
o Proh~ition from iobbyfng befrne boeitd/oornmtfb~ you have served on for period of one year ate' isavirt9
Beai~'t City Code sscldor- 2-26). Miami-Dade County Code seidion 2-11.1).
o Requirement fD disclose certain flnartc~eil irtberesls and gifts ( Ibition, during tenure and for ore' year after leaving office
(re: CMB Corrirrtttrdty Commttbee): prop.
from having any irttersst in ar rt?foeiving any benefit from Community Devebpnierit Stock Grant Raids for eitt>er Yourself .
or those with whom you have bt~irlttss or immediate family ides (CFR 570.611).
Upon request, of these lases ~Y be obtaitred from the City Clerk.
"1 hereby ~~ to the accuracy and tnttttfulness of the appticretton and have received, read and will abide by Chapter 2,
A 'cle VII - of the City Code "Standards of Co uct for City Officers, Employees and Agency tYNmbers."
' ' /~ H of Applicant E PRI
plicarit's Sig rE
Please attach a copy of your resume to the applttreti~n ~~ on the for a period of orre (i- calenriar year
Nt3lE: AppNs:ations
Received m try City Clerk's Office by ~ ~ pate_~I ~ ~l ~ ~,orttrol No. Date: _' 2009
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