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Apt No. Hous No./S
PHONE: ~ D
c-TY OF MIaMI B_acl~
BOARG AND COMMITTEE APPLICATION FOP.M
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Name
~j f~ Middle Initial
~' (~~~ ,CSP,l~ ~~ ~L ' ~ lYD
City State Zip Code
Hom Work Fax EmaK addres~p~~~~. i,.~ r~.t~-,
Business Name: ~~~~ cap ~ .~d7 ~!f Position: ~~J~~.P~-
Address; 7DJ ~ /i`~,,v ~~„lji~t,• ~/ .~.~61' ~`7a~, ~ ~._ L f'L ~3 l~/d
No~j f ~ Street City State Zip Code
Professional License (describe) ~ / Qn(~ 1~ ~ Expires: ~~I~ ~0/a q~ch a copy of tt-e 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 for a minimum of six months in a busines~esta~hed in the city.
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• Resident of Miami Beach for a minimum of sa (6) months: Yes,~or No D -=a ~, ~
• Demonstrate an ownership/interest in a business in Miami Be ch for a minimum of six (6) months: Yes r N ~ -~
• Are you a registered voter in Miami Beach: Yes ~or No D ~ ,.~
• (Please circle one): I am now a resident of. orth Beach South Beach Middle Be --
• I am applying for an appointment because I have special abilities, knowledge and expo nce. list flow-- .,'~
• Are you presently a registered lobbyist with the City of Miami Beach? Yes D or No~. cr: ~°' -"~~-
~, ~ T
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3j third choice. Please~iote ghat onl"v three i'31
choices will be observed by the City Clerk's Office. (Regular Boards of City) ~' W
D Affordable Housin Adviso Committee 0 Housin Autho
D Art in Public Pieces Committee D Laan Review Committee
^ Beautification Committee D Marine Autho
D Boarc! of Ad'ustrnent'` D Miami Beach Commission for Women
D Bud Adviso Committee D Miami Beach Guttural Arts Coundl
^ C ital im rovemerrts Pro'ects Oversi ht Committee D Miami Beach Sieber Cities Pro ram
^ Committee on the Homeless D Namtiand Shores Local Govemmerrt Nei h. Im rovement
D Committee for Qual' Education in MB D Parks and Recreation Facilities Board
D Commun' Deveio merit Adviso D Personnel 8aard
D Commun Relations Board D Piannin Board"
^ Convention Cerrter Adviso Board 0 Police Citizens Relations Committee
D Debarment Committee D Production indu Council
D Desi n Review Board` Public 5a Adviso Committee
D Disabil' Access Committee ^ Sa Committee
^ Fine Arts Board D Sin le Famii Residential Review Panel
D Ga ,Lesbian, Bisexual and Tran ender GLBT D Sustainabif' Committee
D Gotf Adviso Committee D Trans aren Reliabil' & Accountabil' Committee "TRAC"
Health Adviso Committee ^ Tran ortation and Parkin Committee
D Health Faalities Autho ' Board D Visitor and Convention Autho '
^ His anic Affairs Committee ^ Waterfront Protection Committee
D Historic Preservation Board D Youth Center Adviso Board
"Board Required to Flie State Disclosure Form
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 C No C Years of Service: ~ ~' ~ ~~ ~' ~`1 ~ ~ ~ ~ -~ j
2. Present participation in Youth Center activities by your children Yes_~ No =. If yes, please fi~~th~~~es pf your children, their
ages, and which programs. List below: I ~ ~~~r O~OZ
Child's name: Age: Program: } ,`~.p,
Child's name: Age: .Program:
F:\CLEP.'.~ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.do:
.Have you ever been convtcte~ of e felony: Yes ~r No . 1` vas. please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ~.
yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes _ or~~lf yes: explain in detail
• Are you currently serving on nyyC/}ty Bo rds o Committees: Yes or No -. If yes, which board?
~~ ~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:
0 T ~lw•,-~v f~~ -
• I am now employed by the City of Miami Beach: Yes D or N~hich department
• Pursuant to City Code Secfaon 2-25 (bj: Do you have a parent a, spouse D, child C, brother C, or sister ~ who is employed b~~ the
City of Miami Beach? Gheck all that apply. Identify the department(s):~~
The following information is voluntary and is neither part of your application nor has any bearing on your consideraflon for appointment. It is
being asked to comply with federal equal opportunity reporting requtrements.
Gender: (~!Niafe ^ Female
Ethnic Origin: Check one only (1)
~Whlte (Not of Hispanic Origin): All persons having origins in any of the original peoples of curope, North Africa or the Middle East.
^ African-AmericarilBiack (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
^ Hispanic: All persons of Mexipn, 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 cast, Southeast Asia, the Indian Subcontinent, on
the Pacific Islands. This area iredudes, 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 maintain
Cultural iderttifrwtlon through tribal affliiation or community recognition.
Physically Challenged: Yes D or Nolte. ""
Employment Status:
Retired 0 Homemaker p Other ^
NOTE: if appointed, you will be required to follow certain caws which apply to city boardlcommlttee membees.
These laws include, but are not liml6ed m, 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 boardlcommittee you have served on for period of one year afhar 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: CMS Community Development Advisory Committee): prohibition, during tenure -and for one year after Isa4ing 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 ices (CFR 5ZD.611).
Upon request, copies of these laws may be obtained from the City Clerk.
"I hereb fleet to the curacy and truthfulness of the application and have received, read and will abide by Chapter 2.
Article - of the C e "Standards of Co uc for City Officers, c ployees and Agency Members."
~ D ~~
A is Signet Uate Name of Applicant PLcASE P NT)
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 m the City Clerk's Office by ~ ~~ J~~-1(`17~~/ DateO~~~/~ ontrol No ~ / ~7 Date: ~ I p120ba O