Bradley Wells~ ~ ,-
NAM:: `r 1, ~1~ -/
Lasi Name
HOM? AppR°_S5: Io 3~~_
CfT`i OF Mla,l/II 3_:aC'r'
3D,:.RD AND CO(JIMIT i °_c t.P?!_ICF.TIOh' =0 ;M.
IdIddIE
business Name:
Address: I~ ~`
No. Sveet Clty State Lio »od_
PmiaeEional Licen>e ioeec!'Ibe) ~ Expires: Ary:cn t copy or>!re li~en,b
Pursuant to Clp~ Code section 2-^^<2(4) a and o: Members of agendas, boards, ane commiaaes shall ba amllatad wiir, th°- city; rhis
requirement shall be ivlfillod in the following ways: e) an individual sha(I havz bean a resident of the ctty fir a minimum of sir:
months; or b) an indviduual shall demonstrate dwnsrshipfirltaras, for a minimum of six months in a pusiness e~rablished in EnE cin~.
• Resident of Miami Beach for a minimum of sir (6) months: Yes~i or Ne 0
• Demonstrats an ownarsnipiime2st in z business iri Miami Botch for a minimum of six (6) months: Yes D cr No e7
• Are yap a ranistered voiar in Miami death: Yaa D or No D
. (Pleaserprde one): I am now a resldanl o*, NoRh Beach Soufh Beach Mlddte Beach
. I am applying for an appolnimont decease i have zpscial abilifias, know a 9e and experisn:,e. ~Pleasa. list belovr.
• hrt~ you presarrtly a revisterad ivpbyist vrith fie CRy o. Iviiami Beach? Yes G or No~
Plaa:e list your preferen:e~s in order of ranking j1] firer choice ~i ascond choice, and 131 thirri choice. Ploaoe npte that only three x31
ehbl=ae II be ohservrtl Dv the Chv Cloflr'c Oj(IVe.~(Regular Boards of Ctty)
G AfiorCeble Housin ~Advmv Cvmmftfee G Housrnc Authari •
D An In Pup6c Plagec Committee D Lo RaV1aW Comm' +rf3D
D BoauBncRlion Commi~o I D Marine Atrtlto
D Board of'Ad'twvnent ^ Miami B®ecri Commimi~n for YJbmen
p 3ud at Adviyo CommlDee D Miami Beach Guttural Arta Coundl
D Ceaitnl imvrvvemorrta P ~e~s Ovarbi ht Cwnmt[~e _
^ Miirmi Beach Blatar.Ctties Praorem
^ Committee on the Homeless G Nomtand a^tnrea Local Oowmmem Neigh. ImprV+Bmatn
G Commtttea for quaf i5durahon in ME D Pews and Rewation Facilibes 9oard
D Communiiv Devatdomem Advirarv D Persdnnu Boart;
D CommuntN RgtatloR. 9oard D Plannln Board'
p Cgnvp,Piion Carder ~AVv~eg Board D Fo6ra Ci~ena Rc3auons Commtaae
D Debarment Commitfae 0 Produliion Industry.Counril
O Design Rsviav.~ Boa.¢r ; 0 Public Safe Advisorv Committee
D Oisabiliiy Aarr~s Comminee ^ Saien~ Committee
D rme ArG Board D Sin k~ Family Reaidertiial rZaview Pene!~
0 Gav. LSSbian, Bisexual and Transdenvw (GLE7 0 Sus;alnabllrty Commtltec
D Galt Advtsorv Commltiae D Transoaren Rsliabtli ~ 8 Accountability Commitieo '?RAC'
p Haatm Advisory Commlbee CTranswrtalion and Psrkino Committee
I D Health Fedltties Authors Boart __
D vieror and Convention Avtirori v
D Histanic Af(virs CommrDOe _
Jakeriront Pmisdion r'ommhr~e
D Historicrreservation eoarJ _ D Yount r„m„~ Adaicon~ 3oard
1 --"-
"Board Required to File State Oiaclocure Form
Nate. if applying iar Ygtrtn Advisoq~ °oard, piaese indieata your afriliaiian uritn the Scatl Rahgw Youth Camar,
5. Pest s~n~oe on the Youth Center Advisory Boars: kas r. No D Years ai Sorvica:
~. Present perlidpztlon in Youth Comer actwhias by your chllpren Yes~~ Ne =, I. yes, piaese
dams, and whi„h programs. Lis; betov.~:
Chllo-s ham=: ane: _ Prdaram: _
j Chhd's hem='. _ yo=: _ Propfarn~
-..=l°_B',:Al'.\c%7RM.:. ~eD~+Ru aND ~•DMMnTcS~EC ACOliwtton0526b° N°iN.cr.
list the names o! you• chlldrer, their
S`
~,av° you ever beer. cJnv,^mc v' a felony `fe=_ o• No "yes. pie25e veylair ir. oe:ail:
. Uv you eu ,tly nave d woia~iipnis) of Gity of P/~iami 3sa-t: _c s'. Yss `~/or No . I`y._:, pl=_ass s>:a:a:n c. d=_;ail.
'I fa'~t T~~O'f" ~ }If-:r,ri,>r >^~-~-`tom a~~"~Iri
• Do you ;-urr9nily ow_ the Giiy oi. Miami Bead, any menay: Yes = or No~j: I` y?s. s, plain in detail
. -Are you currently servinc an ?ny ::ity boards or Committees, Yes ' or No ~ li yes wMch: hoard
. VJhat organ;zdtiOns in the Giiy of Miami BeaCN de you currently hold membership in?
Name: Title:
Name, Title:
• Lisi all properties ovunad or have an interest in, which are lo:ated within th=_ Glty of Miami Beach,
• I ?m nova employed by the Giiy of Ndami Bsaoh'. Y_s G or NgXj. whim department?
Putsuam to ~ Ctty Code SaeGvn ?-25 (bj: Oa yov hav=_ a parent -. spouse _, child _, orothsr G, orsi~r G vrho is empiwad ny Ina
Chy o`. Miami 8oaon? Check alt that apply. Irierrfihf the deparvnsnt(,s):
Tn¢ fotiowtng irtformetion b voluntary and !6 neRhvr pan of your appll.:a@on nor has any bparfpg on your consideraflon for eppmntmnn:. a is
oeinQ ¢ok¢tl h comply' with taderel equal oponnunhy reporting requlremontt,
Gender: ~ Male ^ Female
CthnfC Orifptn: C;neCk on? cnly (7)
Wnlte (lyo( of Hispanic Origin): All person; hzvlr~ odplnc In any of ins or'y inel pagpleq of cyrope, kotfh Africa or tnE Midtllc 4ai
^ Nrfan-AmwriranlBta_k (Npt d Hixene OrIpInJ: All persvnr. having eripins in any d the BIaJ; radpl proupc of Atifta,
Hle~psntc; All persons of M¢dctn, Pletfi Klan, Cuatat, Cernrel pr 3pu:h cm9rican. or ether 3ovnlan culture orpnotn. ragardleds o: rnce
~ Asten or Ppclfiv kttmrurr: All ptaxons haNttg otip'vts in any of the o(iginal pgoploo of the Ps 1st, Soulntsa_:t Aare, tt¢ Indian StNC~niinaY.. or
the P.uific talnrtds. Ttris ores at:kMea, tvr exdmpir., C3dn4 Mdm. JePM, Korea, !hs Pnelpplne Iarand; end Somafl.
J Amoticen indlan or Alenkan Native: All garcons httvin? origins In arty d ttu oitpmal peaDles of Nptm Arnerlee„ and vmo mammert,
CuM+af kierlriflcxfibntitcotrgh 1rma1 afiCiallon m vomrtumt'y recopnltion,
Phwkealfy Cttalienped: Yes 9 br NoY~
cmploymertt Status: 2mptoyed~ RstlrgJ D Homemaker ^ Other D
NOTi:~ if a:ppoltrtnd, you will 6e-requited to toiVtsw curtain laws vitich apply to city bpondlcpmmttiac members.
These tows inGUdc, buE are hat Rm14rd fa, tt+e following:
p Prphlbtttan from diradly or irulirodly lobtryinp City psrconnel (Miami, r`,e,aeh City Cotle suction ?.-~5a).
o Prottibifion from coniracfing with :he cih~ (Miami-Dade County Code sedion 2-~ 1.5 ).
c PrChiniiion item loopying oafirb baar7lcammllt°e you hav=_ srv=_d are far parted e. one year afizr lea,nnp nfit~ thtcam,
Beach City Code section ;,-26),
RSquireinem tb tll~low certain nnzncial irt6eresM and gift: (Mlzm~-Dade Cautery Cone sac5an 2-.1. i },
(rv: Ctv18 Communth Devnlvpment kdvisory Committeel: prohiaiiion. during tenure end for one guar Wier losrhg nrtics
tram having any irttar>Nt in or rc~iving any benefit horn Gommunify Developmeni~i3tock Oran funds for aHher yauraH
cr those vAth whom you have ovaineas or tmmedlat"_ iamny tle5 fGFR 590.611).
!ipon requec:, cpple, of these haves may be obtained from the CM CInN
"I horeby atxest to the aecutacy and trutittvtnass bf the application and have received, read .and wilt sbltlc ny Onsety, 7..
tyriele vIl--~f the Ctry~ "Srandarrts bf Conduct for Chy Ofiioars. 5mploywac and Aft®ney rhambors."
plv7s¢ tlbt:h o copy pf vour resume to tMc eppllcatiun
NOT.; npplicenons.wlll remain on ilia for a ceriotl o7 she f l i caienoar year.
ttecerw_c m ins : nv ricers .~rnpr, m, Bata _: ~yg Camroi n+p Z. Z Oda _~.-~a~~:
Mama of Uopur'/ =fen:
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