Noreen Legault-Mendozai
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La//st Name
HOME ADDRESS: ~ ls? ~ S ! \
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~ ~~ Middle Initial
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No. ~ Street z
City State Zip Code
PHONE:
Home ~- Work Fax Email address
Business Name: ~`7~-~~~ I ~~ic_/ 1 ~~ v~~' 1/TPosito/v ~ C /l~~jv/ C~0
Address: ~ O~O .~ ~ l r7'(C~/ i~,l /T~ ,~1~ ~' / . ~ • /~~ .~ , ~ ~ 3~J
No.
Professional License (describe)
Zip
Expires: ~`ttt~ch a c;ca~y r~3 the ficens~+
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; orb) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
o Resident of Miami Beach for a minimum of six (ti) months: Yes ~, or No ^
o Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes r No ~-~
o Are you a registered voter in Miami Seach: Yes ^ or No~ ! ``
o (Please check one): 1 am now a resident of: North Beach ^ South Beach ^ Middle Beach ^
o I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
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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 Citv 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
Street
^ Housing Authority*
^ Loan Review Committee*
^ Mayor's Green Ad-Hoc Committee
^ Marine Authority*
^ Miami Beach Cultural Arts Council
^ Miami Beach Commission on Status of Women
^ Miami Beach Florida Sister Cities
^ Normandy Shores Local Gov't Neigh. 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 Committee
^ Visitor and Convention Authority*
^ Youth Center Advisory Board
1
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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 ^ or No ~' If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ~ or No~ If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ~J or No~ If yes, explain in detail
. Are you currently serving on any City Boards or Committees: Yes ^ or No~ If yes; which board?
. What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Name:
Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes ^ or No[~Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ^, child ~, brother ^, or sister a who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
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This section is "not required" but desired: Age: ~~ years old Gender: Male ^ Female
Ethnic Origin (Check one)
White ^Afrlcan-American/Black ^ Hispanic: ^ Asian or Pacific Islander ^ American Indian or Alaskan Native ^
Employment Status: Employed ^ Retired ^ Home-maker ^ Other ^
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Articlexll - ~e City Ade "Standards of Conduct for City Officers, Employees and Agency Members."
® D~c'G/lr G.~ ~U~ ~ [~
Date Name of plicant (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 City Clerk's Office by Date ( ( L" < ~
Name of Deputy Cler~k~/~
Document Control Number (Assigned by the City Clerk's Office) ~~- f-~ Entered By - _ _ Date ~ ~ v
Revisetl 1/25/07jo
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