Daniel Renzi~ ~1i \ ~ ~ C[TY OF MIAMI BEACH
' BEACH
BOARG AND CQMM(TTEE APPLICATION FORM
NAME: 'eq~~
Las! Name First Name Middle Initial
HOME ADDRESS:~~ 135 3eFFers~, ~. ~fl`ec,.; ~a<ti FL ~,313Y
Apt No. House No./Street CRy State Zip Code
PHONE:
Business Name: F~nr~d.a h`4~N.~a ~-~'~T/U~W~Posftion: :`f'°y
Address:
No. Street Ciry State Zip Code
Professional License (tlescdoe)
Expires: Attach a copy o/the license
Pursuant to Clty Code section 2-22(4) a and b: Members of agendas, boards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shell have' been a resident of the city for a minimum of six
mordhs; or b) an individual shall demonstrate ownershiplinterest for a minimum of six months in a business established in the dty.
• Resident of Miami Beach for a minimum of sa (6) months: Yes~or Ne ^
• Demonstrate an ownershiplimerest in a business in Miami Beach for a minimum of six (6) months: Yes ^ or No D
• Are you a registered voter in Miami Beech: Yes ^ or No 0
• (Please circle one): I am now a resident of North Bsaeh South Beac Middle Beach
• I am applying for an appointment because I have specal abilities, d experience. Please list below:
• Are you presently a registered lobbyist wNh the Ciry of Miami Beach? Yes D or No ~( - ~t'`~5~"~/ ~(~'
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Please list your preferences in order of ranking (T) nrst cnorce Iz) secene choice, ane [3) tnrrd choice. Please note that omv three fSl
choices iwtil be observed by Me Chv ClerMs Office. (Regular Boards of City)
C Aflordeble Houein Adviso Commlttee D Housin Atdho
D Art in Pubhc Places Cammiftee ^ Loan Review Commitlee
^ Bealdlfication Committee D Marine Autho
^ Board of Ad'usfinerd' ^ Miami Beach Commssion for Women
D Bud t Advia Cammlbee D Miami Beach Cultural Arta Coundl
D C Itel Im merrN Ovens Ctmrmil~e taint Beech Sir Cities P ram
^ CommtCee an The Homeless D Notmend Shores Local Govammertt Nei h. Im rovemern
D Committee fir t]ua Education in MB ^ Perks and Recreation Facilities Board
D Commun Davela ment Adviso D Personnel Board
D Commun Relations Board ^ Plennin Board"
^ Convention Center Adviso Board ^ Paiice CIC¢ens Relations Committee
D oebarmem Commlaee ^ Production tnd Coundl
0 Desi n Review Board' ^ Public S Adv~o Committee
0 Disabll Access Commthee ^ S Committee
D Fine Arts Bcard C Sin N Femil Residerdial Review Panel
^ G .Lesbian. Bisexual and Tren ntler GLBT D Sustainabii' Committee
^ Goli Adviso Committee ^ Trans wren Reliabll' & Axountebif Commibee 'TRAC'
D Health Adviso Committee ^ Tre ortation and Parkin Committee
^ Heatth Fadltties Atrtho Board 0 Visitor and Converdion Autho '
D His nic Attains Committee D Waterfiorrt Protection Committee
^ Historic Preservation Board ^ Youth Gentler 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 Cerrter.
1. Past service on the Youth Center Advisory Board: Yes ~ No =~ Years of Service:
2. Prasem partiapation in Youth Cemer activities by your children Yes=~ No = Ii yes, please list the names of your children, their
ages, and vmich programs. Gst below
Child's name Age: Program:
Child's Hems:
Ac=~ Program:
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•~ave yap ever o=en convlcte~ o` G felony Yes ~ No I' vas please explain in tletait:
• Do you currently have a vloiation(s) cf City of Miami Beach nodes. Yes . or~io~lf yes. Please erptalr in detail:
• Do you currently owe the City of Miami Beach any money: Yes . or~io~J~i yes. explain In detail
• Aro you currently s=ruing or any City Boards or Committees. Yes " oq~io~ ~ yes', wnlci ooard?
• Whanizations in the Ciiy of Miami Beach do you currently holtl membership In?
Na,~ ~rsr a olrPru~iOi aP '~i,c~/e53 , Title:
Name: ( C7V1Lnkc ~,~as.-, ~s~,G ~.r~~ 3_ Title:
• List all properti~ ned or have an interest in, which are located within the City of Miami Beach:
• I am now employed fly the City of Miami Beach, Yes D or ~~?~Jhich department?
• Pursuant to CFty Code Seeffon 2-25 (b): Do you have a parent ~, spouse ^, child C, brother C, or sister D who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ,t,~
The following informadon Is volurgery and Is netther pert of your epplleadon nor has any bearing on your conaidaredon for appointment. It Is
oeing askatl to comply with federal equal opportunity reporting regWremerds.
Gender: ~ Male 0 Female
one only
WhHre (Not of Hispanic Origin): Ail persons having origins in any of the original peoples tlf Europe, North Afnw or the Middle East.
Q Afriean•AmerieaNBtaek (Not of Hlaptmlc l')rtgfn): All persons having origins in any of the Black racial groups of Africa.
Hispanic: All persgns of Mezicen. Puerto Wean, Cuhan. Central or South Ameripn, or other Spanish culture or ortgln, nrgeroleas of race
i7 Asian or Paelfk felenrier: All persom having origins in any of the original peoples of the Far cast, Southeast Aeie, the Indian Subwnlinenl. or
the Padfic Istaruts. This eras erdudes, Iqr example, China, India, Japan, Korea, the Philippine Islands antl 5omoe.
American Indian or Alaslun Natlve: All parsons having origins in any of ttre original peoples of North Amadce, and who mairdatn
Cusurel idemffics9on through tribal aflgiafion or community recognition.
Phvsieally Challenoent: Yes ~ or NoO.
Employment Statu~Emptoyeo'~~Retired 0 Homemaker p Other ^
NOTE: If appoirfte ,you will be required to follow certain laws which apply to city baardlcommkhae members.
These taws 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 Prohibtion from commuting with the rdty (Miami-Dade County Code aecfion 2-11.1).
o Prohibition from lobbying before boaml/committee you have served on for penotl of one year after leaving office (Mlam~
Beach City Code section 2-26).
o Requirement to diacloee certain fatancial irttelests antl gifts (Miami-Dade County Code section 2-11.1).
(re'. CMB Community Development Advisory Committee): prohibttion, during tenure antl 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 taws may be obtained from the City CIerY..
"I hereby attest to the accuracy and truthfulness of the application and have received, road and will abide by Chapter 2.
Artic II - of the Clty C fe "Standards of Conduct for City Officers, Employees antl Agency Members."
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Applicant's Signature Date
Na
SE PRINTI
Please aaach a copy of your resume t s applleation
NO : A plieetions will remain on r a penotl o1 one (1 j calenaer year.
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