Antonio M. Hernandez, Jr.>/ ~ i .t ~~~ \/~t ~ ~ ~,~~ ~ CITY OF Mli"-,IJII 3EI~Ci-I
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BOARG AND COMMITTEE AP?LIC<;TION FOP.M
NAME: ~~ r-1 4vi ~Z J ;! ~'ry ~l'Y ~
Las! Name O~0 ~0.,,.~/ o rust Name ~ ~ Middle Inltlal
HOME ADDRESS: rho AVC- /~'li~^'~',~ ~~'=^-d`"t ~ .33~Y~
Apt No. ~ House No./Street City State Zip Code
PHONE;
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Work
Fax
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,,,,,~ ,A~ // Email address
Business Name: /(~~~1- Position: /y~
Address: N~~`
No. Street City State Zip Code
Professional License (describe) Expires' Attach a copy of the license
Pursuant to Clty Code section 2-ZZ(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 i n a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: Yes ^ or No 0
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes D or No 0
• Are you a registered voter in Miami Beach: Yes ^ or No 0
• (Please circle one): I am now a resident of: North Bsach ~ South Bsach Middle Beach
. I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes 0 or No 0
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)
D Affordable Housin Adviso Committee D Housin Autho
D Art in Public Pieces Committee ^ Loan Review Committee
0 Beautification Committee ^ Marine Autho
^ Boarcl of Ad'ustrnerrt' ^ Miami Beach Commission for Women
D Bud Adviso Committee 0 Miami Beach Cultural Arts Council
0 C ital Im vemerrls ctss Oversi ht Committee 0 Miami Beach Sister Cities Pro ram
^ Committee on the Homeless D Normand Shores Local Govemmerrt Nei h. Im rovement
^ Committee for Qual Education in MB D Parks and Recreation Facilities Board
D Commun Devei ment Adviso ^ Personnel Board
D Commun Relations Baan:l D P in Board'
0 Convention Center Adviso Board office Citizens Relations Committee
D Debarment Committee ^ Production indu Council
D Desi n Review Board' ^ Public S Adviso Committee
^ Disabil Access Committee ^ 5afe Committee
0 Fine Arts Beard 0 Sin ie Famit Residential Review Panel
D Ga ,Lesbian, Bisexual and 7ransaender GLST ^ Sustainabif' Committee
0 Golf Adviso Committee 0 Trans aren Refiabil' 8 Accountabil' Committee 'TRAC"
^ Health Adviso Committee ^ Tran ortation and Parkin Committee
^ Health Faalities Autho Beard ^ Visitor and Convention Autho
D His anic Affairs Committee ^ Waterfront Protection Committee
D Historic Preservation Beard D Youth Cerrter Adviso Board
"Board Required to Flle State Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center.
.~~0 $,~~~?,~ ~11~
1. Past service on the Youth Center Advisory Board: Yes C No =~ Years of Service: y'
2. Present pip~tir~dn ~tptl~~pr~r0~ctivities by your children Yes_~ No 'r. If yes, please list the names of your children, their
ages, and wh-ch programs. ~ ~ h.
Child's name: Age: Program:
/~ .:~ .
Chitd~s name: Age: Program:
F:\~LEP.`.SAL'\o~~RMS~B~ARD ANC ~OMMITT~E~\B~ ApplicpnonOG2604 N.V\',00: /~
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