Marc Gidneym ~ :/'~ I.~„',i~ BEACH CITY OF MIAMI sEACr
/~ BOARG AND COMMITTEE APPLICATION FORM
NAME: ~ ~~N ~ ~~ C
Las' Name nrst Name Middle Intdal
HOMEADDRES5:/f53 /3t~'~,rw'R-Ir-c rr.~~c _ /la•c}u.pe0 .i=~ ?fU/~
Apt No. House No./Street rtY State Zip Cotle
PHONE: 30.C`-- 6 ' 6 Z~O ~ 3 6.f = ~~~ - 6 ~7~
Home Work Fax EmaII address
Business Name: ~/ON F Y ~ CU,•,/mod _S ~_~'_~~ Position: Bw+r ~c.
Address: 32(0 - ~/STS~2 F~ T, ~~~w, ~~~~~ ~~ 3?/y /
No. Street Ciry e~ State Zip Code
Professional license (tlescdbe) G P~ Expires: b ~/"'-' Attach a ropy o! the license
Pursuant to Clty Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
requirement shalt be fulfilled in the following ways: a) an individual shell have' been a resident of the dtY for a minimum o1 six
months; or b) an individual shall demonstrate ownershipAnterestfor aminimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of sa (6) months: Yes ^ or No D
• Demonstrete an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes D or No
• Are you a registered voter in Miami Beach: Yes D or No ^
. (Please circl one): I am now a resident of North Beach South Beach Middle beach
• I am applying for an appointmerrt bepuse I have special abiltties, knowledge and experience. Please list below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No 0
Please list your preferences in order of ranking ~1) first choice (Zj second choice, and [3) third choice. Please note that only three f81
choltxa will be observed by the Ckv Cleric's Office. (Regu{ar Boards of City)
D Affordable Housin Adviso Committee ^ Housm Autho
0 Art in Public Places Ctmrmitme D Loan Review Cotrrmittee
^ Bearttification CommiCae D Merino Autho
^ B b of Ad'ttatmerd' D Miami Beach Commission for Woman
ud Adviso Ctrmmitlee D Miami Beach Cultural Arta Couridl
0 C qal Im merits Overs' CtmrtnHtae D Miami Beech Si6ler Cities P ram
^ Committee on the Homeless D Normand Shoes Local t3ovemmerrt Ne' h. Im rovemerit
^ Committee fir Oual Eduestion in MB D Perks and Retaeation Fecllifies Board
D Commun Develc ment Adviso ^ Personnel Board
D Commun Relations Board ^ Plennin Board'
^ Convention Carder Arlviso Board ^ Police Cit¢erw Relations Cammlttae
^ Debarment Committee ^ Production Ind Council
D Desi n Review Board' D Public S Adviso Committee
D Disabil Access Committee ^ Sa Committee
^ Fine Arts Board D Sin N Femi Residential Review Panel
D Ge .Lesbian. Bisexual and Transcender GLB D Sustainabil' Committee
D Golf Ad Committee D Tra aren Reliabli' & Atsountabfl Committee 'IRAC'
D Health Adviso Committee D Tran ortation and Perkin Committee
D Health Fatalities AtAho Board ^ Visitor and Convention Atttho '
^ His nic Affairs Committee D Waterfront Protection Committee
D Historic Preservation Board D Youth Center Advisory Board
~ `Board Required >a Flle State Disclosure Form
Note. If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Cartier
t. Past service on the Youth Center Atlvisory Board: Yes D No'! Years of Service:
2. Present participation in Youth Center activities by your children Yes ~ No C. Ii yes, please list the names of your children, their
ages, and which programs. List below:
Child's home.
Chiltl's name:
Age: Program:
Ape: Program:
F ~CIGP`.SA!'. ~o°JRM5~67ARG AND ~7MMnTa\B~ AoolicanonDG260S N=~'.doc
-clove you ever peen convicteC o' ~ i=long Yes a~No P yes please _xpiain in oetaiP.
• Do you currently have a violation(s) o` City o? Miami Beach codes. Yes . ~ "_.. It yes, cicala erpialn in detail:
• Do you currently owe the Cfty of Miami Beach any money: Yes . or No .-~es explain u. detail
• Ar= oudcurrently servino or any City Boards or Committees- Yes or No ' I? yes; wnict ooard?
,r
• What organizations in the City of Miami 3each tlc you currently hold membership m?
Name: Title:
Name Title:
• List all properties owned or have an interest in, which are lo,^.ated within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes r~ or Nom vVn(ch department?
• Pursuant to City Code Section 2.25 (bj: Do you have a parent p, spouse Cl child C, brother C, or sister p who is employed by the
City of Miami Beach? Check all that apply. Identify fhe department(s): y/~~
The following informetlon le volumary end Is neither part of your appllcadon nor has any bearing on your eonaideredon for appointment. tt Is
oeing asked to ~~~omply with federal equal opporbmpy reporting requtremeMS.
Gender: B'Male ^ Female
one only (1j
! yWhhe (NO1 of Hispanic Ongin): All persons having tnigins in any of the original peoples of Europe, North Atrfw or the Middle East.
^ African-Amerieenl6laek (Not of Htapenlc Or(gin): All peBOns having origins in any of the Bieck racial groups of Afirs.
^ HYepanlc: All persons of Mexican, Ptlelio Wean, Cuban, Carttrel or South American, or other Spanish vulture or oright, regardless of race
:J Allan or Paelfic istentier: All persons having rniAfm in any of the original peoples of the gar cast, Southeast Asia, the Indian Subcontinent, or
the PaGfic Islands. Thk eras kroftafea, for exantPie, China, fndia, Japan, Korea, the Phitlppirre Islands arW 3omoe.
Amerteatt Indian of Alaell®t Native: All parsons tteWrtg origins in any of the original peoples of (dorih America, and who rtairrtetri
Caporal kterrtHleeson through lAbal atppapon or eommemMy recogrdkon.
Yea p or Nop.
Employment Status: Employed ~ Retired 0 Homemaker ^ Other 0
NOTE: If appoitrted, you will be reglthed to follow certain taws which apply to dty boardicommltlee members.
These tatars include, but are not ItmNed to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
c Prohibition from contracting with file dty (Miami-Dade County pose aedion 2-11. t ).
o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miam:~
Beach City Code secpon 2-26j.
o Requirement to disclose certain firtltncial imerests and gifts (Miam~Dade County Code seepon 2-11.1).
(re: CMB Commttnpy Devetolxnem Advisory Commptee). prohibpion, during tenure arid for one year atfsr leaving office
from having any vt~tast in or receiving any bartefrt from Community Development Block Gram funds for epher yourself
or those vAth whom you have buaineas or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtairred from the City CIerY..
"I hereby
pft6fhe a uraey and truthfufneas of the application and have received, read and will abide by Chapter Z
the C~ a "Standards of Conduct for City ORicers, Employees and Agency Members."
//yD /se~0
attach
• i uatq Name of Apoocanl (PL'cASE
o! your resume to this appltefltion
NOTE: Applications will remain on flee for a period o1 one (1) ealenoer yeec
rtecerved m the :rty Clerk's J(frce oy Gate _~ 2l)Oy ;;ontro~ No foss Uare _ _, pDP
Name of Ueputy earl: