Michael L. Burnstine ApplicationNAME: Burnstine Michael L
Last Name First Name Middle Initial
HOME ADDRESS: 4447 N. Bay Road Miami Beach FL 33140
Apt No. House No./Street City State Zip Code
PHONE: 305-984-6200 michael@burnstine.com
Home Work Fax Email Address
Business Name: Lockton Companies
Address:
Position: Vice President
3601 SW 160 Avenue, Suite 200 Miramar FL
33027
No.
Professional License (describe):
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 for a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: Yes
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: No
• Are you a registered voter in Miami Beach: Yes
• (Please circle one): I am now a resident of: Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
I am applying for reappointment to the AHAC Committee that I have served on from 2007-2009
• Are you presently a registered lobbyist with the City of Miami Beach? 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 City Clerk's Office. (Regular Boards of City)
Art in Public Places Committee Loan Review Committee
Beautification Committee Marine Authority
Board of Adjustment Miami Beach Commission for Women
Budget Advisory Committee Miami Beach Cultural Arts Council
Capital Improvements Projects Oversight Committee Miami Beach Sister Cities Program
Committee on the Homeless Normand Shores Local Gov't Nei h. Im rovement
Committee for Quality Education in MB Parks and Recreation Facilities Board
Community Development Advisory Personnel Board
Community Relations Board Planning Board
Convention Center Advisory Board Police Citizens Relations Committee
Debarment Committee Production Industry Council
Design Review Board* Public Safety Advisory Committee
Disability Access Committee Safety Committee
Fine Arts Board Single Family Residential Review Panel
Gay, Lesbian, Bisexual and Transgender (GLBT) Sustainability Committee
Golf Advisory Committee Transparency Reliability & Accountability Committee "TRAC"
Health Advisory Committee Transportation and Parking Committee
Health Facilities Authority Board Visitor and Convention Authority
Hispanic Affairs Committee Waterfront Protection Committee
Historic Preservation Board Youth Center Advisory Board
'` Board Required to File 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: No Years of Service:
2. Present participation in Youth Center activities by your children Yes If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: Drew Burnstine Age: 8 Program: intramural basketball
Street City State Zip Code
Child's name: Michael Burnstine Age: Program:
• Have you ever been convicted of a felony: No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail:
Miami Beach
• Do you currently owe the City of Miami Beach any money: No If yes, explain in detail
Miami Beach
• Are you currently serving on any City Boards or Committees: No If yes; which board?
I was recently termed out of my service on AHAC
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Miami Beach Chamber of Commerce Title: Pillar Board Member
Name: Middle North Bay Road Homeowners Assoc. Title: President
. List all properties owned or have an interest in, which are located within the City of Miami Beach:
4447 N Bay Road
• I am now employed by the City of Miami Beach: No
Which department?,
• Pursuant to City Code Section 2-25 (b): Do you have a who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
Miami Beach
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: Male Race: White
Ethnic Origin: Check one only (1)
White
Physically Challenged: No
Employment Status: Employed Other:
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee 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,
Article VII - of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
I Michael Burnstine agreed to the following terms on 1/13/2010 7:58:16 AM
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:
Date: _/ _/ Control No. Date: _/_/
Name of Deputy Clerk