Jorge Kupermanm !~,~~ I A.rv~ BEAC H
NAME: {~.V ~i~H t r'r~r
.L~aMSt Name /~ ~ A
HOME ADDRESS: %v ~ `-~ ~ '~ ~7'Yr
Apt No. - House No./Street
PHONE: ~~• ~~~ •g~J~
Business Name:
Address: ~ ' ' ~'
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Professional License ttlesedoe) ~~ ~ `v t
y • State Zip Code ~
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 dtY for a minimum of soc
months; orb) an individual shall demonstrate ownership(nterestfor aminimum of six months in a business established in the dty.
• Resident of Miami Beach for a minimum of six (6) months: Yes ~ or No D
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of sa (6) months: Yes ~ or No ^
• Are you a registered voter in Miami Beach: Yes a or No D
• (Please it g one): I am now a resident of North Beach South Beach Middle aae
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
• Are you presently a registered lobbyist with fhe City of Miami Beach? Yes ^ ar No
Please list your preferences in order of ranking [tj first choice [2] second choice, and [3] third choice. Please ndte that only three l31
etigiees will be observed by the Chv Clerk's OKrce. (Regular Boards of City)
^ Affordable Housin Adviso Committee ^Housin Autho
^ Art in Public Places CommMtee ^ Loan Review Committee
^ Beautlfieation Committee D Marine Autho
^ Board of Ad'ustmertY ^ Miami BeaGt Comm~sion for yVOmen
^ Bud Adviso Committee D Miami Beach Cultural AKs Coundl
^ C flat Im rovements Pro acts Oversi ht Committee D Miami Beach Sister Cities Pro ram
^ Committee on the Homeless D Nonnend Shores Local Government Nei h. Im rovement
^ Committee for Dual Education in MB ^ Parks and Recreation Facilities Board
^ Commun Devel meat Adviso D Personnel Board
^ Commun Relations Board D Plannin Board'
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production ind Council
^ Desi n Review Board' ^ Public Sa Adviso Committee
^ Disabll Access Committee D Safe Committee
D Fine Arts Board D Sin le Farm Residential Review Panel
D Ge ,Lesbian, Bisexual end Trans ender GLB D Sustatnebil Committee
D Gott Adviso Committee D Tre aren Reliabil & Aceountebii' Committee 'TRAC'
^ Health Adviso Committee D Tren ortation and Parkin Committee
D Health Facilities Autho Board ~ D Visitor end Convention Atttho '
D His nic Affairs Commitlee ^ Waterfront Protection Committee
i Histohc Preservation Board ^ Youth Center 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
1. Pest service on the Youth Center~A~v~~ ~oeir)~ ~Yes~~IdrJ'Years of Service: ~ ~ ~-
2. Present participation in Youth Center activities b (lour children Ye_s-~ No ~. If yes, please list the names of your children, their
ages, and which programs. List bel~ :Z Wd .~ ~ Pi~~ D~~Z:
Child's name: Age: Program:
Child's name:
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
. 2~.
Position:
Age: Progrem:
F:\CLEP.\SALL\cFORMS\BOARD AND COMMITTEES~BC Application062609 NEW.doc
l
.Have you ever been convicted of a felony. Yes or Noj~lf 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 _ or No iff tf yes, explain in detail
• Are you curcently serving or. any City Boards or Committees: Yesror No =... If yes; which board?
~'44b1~.1ltdtG -~p~~[~ .. .
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
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 No3. Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ^, child G, brother C, or sister:? who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
The following information is voluntary and is neither pert of your applidatlon nor has any bearing on your eonsitleredon for appointment. It is
being asked to comply with fetlerel equal opportunity reporting requlrememe.
Gender: tB Male ^ Female
Ethnic
one
^ White (Not of Hispanic Origin): All persons having odgins In any of the original peoples of Europe, North Africa or the Middle East.
^ Afdean•AmerieanlBlack (Not of Hispanic Origin): All persons having origins in any of fhe Black radal groups of Afnca.
~ Hispania: All persons of Mexican, PueM Rican, Cuban, Cemral or Sbuth American, or other Spanish culture or origin, regardless of race.
^ Aslen or Pacific klander: All persons having origins in any of the odgins! peoples of the Far East, Southeast Asia, fhe Indian Subcontinent, on
the Padfic Islaritls. This area indudes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ Ameneen Indian or Alaskan Native: All persona having odgins in any of the odgins! peoples of North Amedca, end who meitdein
Cuaural iderrttficafion through tribal afliaation or community recognition.
Physically Chalfenaed: Yes ^ or NoK.
Employment Status: Employed Retired o Homemaker ^ Other 0
NOTE: If appointed, you will be required to follow certain taws which apply to chy boardicommtltee members.
These laws include, but are not limited to, the following: ~~
i
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with The dty (Miami-Dade County Code section 2-11.1). j
o Prohibition from lobbying before board/committee you have served on for pedod of one year after leaving office (Miami
Beach City Code section 2-26). I
o Requirement to disclose certain financial interests and gifts (Miami-Dade County Code setion 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 beneflt from Communtty Development Block Grant funds for either yourself I
or those with whom you have business or immediate family ties (CFR 57U.611).
Upon request, copies of these laws may be obtained from the City Clerk.
I
"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, Employ~eess and Agency Members."
® `~.
Applleant's SI `~ ~ Ua 2v ~ V me of APPlicenl (PLEA E PRINT)
Please attar a e y of your ras~me to this app! ton
NOTE: Ap liceti ns wl mein file fora of one (d i calendar year,
Received in the Gty Clerk's Office by :~ ~l9r~t!^~ / /~ ~ Date: _/ !2009 Control No. ~ Date ~~1200 ~~ ~
Name of Ueputy Clerk