Seth Frolich Board Application® I• 1. ; !`, ~`, ~`; F`~ ~~~
/ ;,; ~ i ;-,,, ~ .~ CfT`' OF MlAidl! BcACH
- BO ' RG AI~1D COtVItVIi T TEE A.PP~! ICATIOh rOF:IYi
NAM=: ~~ ~
Las? Name First (Jame IJiiddle Initial
~~a ~ . ~:~~~~~ ~~ ~1
HOMS ADDR'rSS; -e'er ,,~ ~ s~ r~~~ %~c,~ t~^j- ~j`~~
Apt No. House No./Sweet City State Zip Code
PHONE: ~~ -a -? Z ~ 3I G 7~,~SLy ~~ ~ (`~S•c%
~„~,e Wnr'M Fax Email addre~~
Business Name:
Address:
v,,es,~-
cx ~.~'rs j
IJo.
Processional License (describe)
.,~
J/( 'P'osition:
s~l;s
Street
City
Expires:,
State Zip Code
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 city for a minimum of six
months; or b) an individual shall demonstrate ownershiplinterest for a minimum of six months in a business estab!'tshad in the city.
. Resident of Miami .Beach far a minimum of six (o) months: Yes No ^
• Demonstrate an ownership/interest in a business in Miami Beach far a minimum of six (6) months: Ye~3-a~ No ^
. Are you a registered voter in Miami Beach; Yes j~br-No D _____
• (Please circle one): I am now a resident of: North Beach South Beach ~ Middle 9sach~
• I am applying for an appointment because I have special abilities, knowledge and experience. Please fist below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes D or No~
Please fist your preferences in order of ranking [1] first choice [Z] second choice, and [3] third choice. Please note that oniy three f3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
D Affordable Housin Adviso Committee D Housin Autho '
^ Art in Public Places Committee D Loan Review Committee
^ Beautincation Committee D Marine Autha '
^ Board of~Ad'ustmertt* D Miami Beach Commission for Women
D Budoet Adviso Committee D Miami Beach Guttural Arts Council
D Ca ttal im rovemerds Pro ects Oversi ht Committee D Miami Beach Sister Cities Pro ram
D Committee an the Homeless D Normandy Shores Local Gvvemment Nei h. im rovement
^ Committee for Qual' Education in MB D Parks and Recreation Facilities Board
^ Community Oevelnpmeni Advisory D Personnel Board
_
^ Comrnun' Relations Board Plannin Bcard*
D Convention Center Adviso Board ^ Police Citizens Relauons Committee
^ Debarment Committee D Production indu Council
^ Desion Review Board" ^ Public Safe Adviso Committee
^ Disabilit Access Committee ^ Safe Committee
D Fine Arts 8aard 0 Sin fe Famii Residential Review Penal
D Ga ,Lesbian, Bisexual and T ransgender ~LBT D 5ustainability Committee
^ Gott Adviso Committee D Trans aren Reiiabil' &. Accountability Committee "TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Huthority Board ^ Visitor and Convention Autho '
^ His anic Affairs Committee ^ Waterfront Protection Committee
^ Historic Preservation Board D Youth Center Adviso Berard
"Board ReQuired to Fiie State Disclosure Form
Note: tf applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
~,
i .Past service on the Youth Ce A~vi~
Z. Present participation in Yout~~ehter~
ages, and which programs. List below:
Child's nom=: f
Child's name:
please list the names of your children, their
Aae: Program:
• ~~ Board~: 1Yes _ No C~ Years of 5ervioe:
~3a'tivit~e~ ~'~~~ ~~iildren Yes=~ Nc C. If yes,
i~ ~, r ,, ~ :~ a a AgF: Program
. a „ -~~* ~~~~ r~ -
.~!=°'',5A!'_\a=~RM. ~6~.AP.G ANC COMM1TTcB~\B~ f.coiiooiion0o2b0~ N~W.oo~
a -tav~ yo:. ova- ;,=gar ~~-;.~:"e~ . ~ ~ ~~~,~n, "e= ;~~. " ~'~s oleos= expfatr, !n ^=rai!.
Co you ; ~Jrr entfy haV~ 8 VIOiHtIOn;S~ 0~ Clty O- t~/liarri~ ~~3C+' ~OdeS Yes ~' tV0 , °S DI :856 eY.Dialr Ir ^eLal!.
~ Do you currently owe the Cit}~ of IJiam; Beach any money: Yes . or No If yes. exotain Ir. detail
~ Ara you currently s°rVlnc or an} ~It} Boards or Commlttess Yes or tJ t` va whlcr ooard~
. Vd'rat organizations Ir, na Cliy o" t~iaml Beaoi"~ do you ~~rrently nolc rnemoersnrF. Ir;
Name: ~~.~f~i,-~ ~t~iL=-"'''~ Titi=
Name: t.?t~- - -~-S,~~r ~'~ Title:
« Lis )~I prope ,, lee owned or have ar, interest in, which a located wJ~thin the City of Niami Brach:
1
. I am now employed by the City of MiamilBeach: Yes ~ or I~o,1-.,Which department?
?urstzant.io City Cade Section 2-Z5 (bJ: Do you have a parent ~, spouse ~, child G; brother L, or
City o fJiami i3Each % Check all that apply. Identify the department(s):
The following irrfarmation is voluntary and is netfher pari of your appticafion nor her any 6saring on your conslderafton for appointment it t~
being asked to comply with federal. equal oppottuntty reporting requirements.
.Gender:
D Female
Ethnic Orig'trt: Check one only (1 j
~ hlte (Nei of Hispanic Origin): All persons having origins in any of the original peoples of curope, North Africa or the Middle Easl.
kfrtcan-AmericanlBtack (Nat of Htspantc.Origln): All persons having origins in arty of the Blaci; racial groups of Africa.
D Hispania: All persons of Mexi~n, ?uerto i~ican, Cuban, Certtral or South American, or other Spanish culture or origin, regardless of race
Aston or Pacific tstander: AI( persons having origins in any of the original peopl=s of the Far _asl, Southeast Asie, the tRdlan Subconfiner.;. or
the Pactfrc !stands. This area includes, for example, China, India, Japan, Korea, the ?Mlippine Islands and 5omaa.
J American lc-dtlan or Alaskan ttafive: All persons having origins in arn~ of the original peoples of North America, and who mairtiarn
Culfurar iderrtfftcafion through trtbal affiftafion or community recognition.
Physically Gitaliengect: Yes ^ or ~}oD
Errtpfoyment Status: cmptoyer~'-r'~etirad 0 !-tomemaker ] Other D
NOTB: tf appoir:-ted, yov wi[[ be-required to toflow certain taws which apply to atty baardicomrnNi~ae members.
These tav~rs include, but are pat ltmifred tn, the following:
i
~ c Prohibition from directly or ind'rrectiy lobbying city personnel (Iviiam~ Beach City Code section 2-~'S9)
c Prohibition from contracting with the city (It/iami-Dade County Code sectior~ 2-1 i .'( )
o Prohibition from lobbying before board/rximrntttse you have served on for period of one year offer leaving ofnce (Nllarn
Baach City Code section 2-26).
c Requirement to disclose certain financial interests and gifts (IViiarrr-Dade County Code section 2-1 i.1).
(re: CMB Communii.}~ Devetopment Advisory Commttteej: prohibition, during tenure and far one year after leaving office
from having any interest in or receiving any beneni from Community Devetopment Blocl; grant funds for either yoursef=
or those with whom you have business or immediate family lies (CFP. 570.611).
Upon ree}uest, copies of these taws may be. obtained from the City Clerk.
"! here y a . st tot accuracy and truthfulness of the application and have received, read and wilt abide by Chaote•
Arttci II f the " ~ Code "Standar~sa#.~errdu~t-for Cit}~ Officers, cmpbyees a d Aoerte^v tVt ~+ be
Ap ~ a f` St nature irate Name of Hpoltcan~ f°' ~P.Sc pRINT~
Ptease attaci' a ropy o~ your resume to this applt~ation _
NQT~: Application rll remetn o , ie tvr ueriorl of one r1 i ^alenaar veer
ReoelVec Ir. tn° :itv ~i=rlt~s Dff~ce o~ Dare /2~QB ~ontro~ No Date _/ZOQ ~~
Name o` Deputy ~lerf. l