Lisette Olemberg Goldstein®.MI/ACMIBEACH
NAME: y~ I d s fi -e.~'n
HOME ADDRESS; Last N;m~.^ ~ `~ ~ ~~ First N~e, ~t~t ~~C~IeilJnitial~~ l~ ~
~ ,~cA~pt No. ~`.1~._7 House No./Street ,~. City State r' Zip Cade
PHONE: ~'W ,~ ~ 3X - ~ ~ ~ g ~\ 5 ~-F-{ ~. ~ a ~ b Sfi"eL. Q ~n-,a c . ca'+'l
~- dome Work nn Fax V` Ema\il address
Business Name: ~ `fVY1 ~.t~e~ l~~ Positiorr SYl aP !1 .~ S 1G!-'G~ ~--
Address: ~~~-'~ NW Z\ 5~ ~~ ~"tel. ~3 ~ ~ ~
Professional License (describe)
Expires: AKach a copy o/the licenso
Pursuant to City Code sectlon 2-22(4) a and b: Members of agenaes, 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 far a minimum of six
months; orb) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the aty.
• Resident of Miami Beach for a minimum of six (6) months: Yes~or No ^
• Demonstrate an ownershiplinterest in abusiness in Miami Beach for a minimum of six (6) months: Yes~(or No ^
• Are you a registered voter in Miami Beach: Yes or No ^
• (Please cirde one): I am now a resident of: orth Beach Soufh Beach iddle Beac
• I am applying for an appointment because I have spedal abilities, knowledge and experience. ease Ist below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No '$[
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three l31
choices will be observed by the Citv Clerk's Office. (Regular Boards of City)
^ Affordable Housin Adviso Committee ^Housin Authori
in Public Places Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Authod
^ Board of Ad'ustmenP ^ Miami Beach Commission for Women
^ Bud et Adviso Committee
^ Ca ital Im rovements Pro'ects Oversi ht Committee ^ Miami Beach CuRural Arts Council
^ Miami Beach Sister Chies Pro rem
^ Committee on the Homeless ^ Nonnand Shores Local Government Nei h. Im rovement
^ Committee for Oualit Education in MB
D Communi Develo ment Adviso
^ Communit Relations Board ^ Parks and Recreation Facilities Board
^ Personnel Board
^ Plannin Board'
^ Convention Center Adviso Board
^ Debamrent Committee
^ Des' n Review Board• ^ Police Citizens Relations Committee
^ Production Indust Coundl
^ Public Safet Adviso Committee
^ Disabiiit Access Committee ^ Safe Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
D
0 Ga Lesbian Bisexual and Tran ender GLBT
^GolfAdviso Committee ^ Sustainabilh Committee
^ Trans arenc Reliabilit & Accountabil' Committee "TRAC°
^Trans ortationandParkin Committee
^ Healih Adviso Committee ^ Visitor and Convention Authori
^ Heahh Facilities Authori Board
^ His anic Affairs Committee
^ Historic Preservation Board ^ Waterfront Protection Committee
^ Youth Center Adviso Board
'Board R wired to Flle Stale Disclosure Fonn
Note: If applying for Youth Advisory Board, please indicate your affiliation with the ScottRakow Youth Center:
1. Past service on the Youth Center Advisory Board: Yes ^ No ~ Years of Service:
2. Present participation in Youth Center activities by your children Yes No ~. If yes, please list the names of your children,
ages, and which programs. List below
Child's name: Age: Program:
Child's name:
Age: Program:
CITY OF MIAMI BEACH
'BOARD AND COMMITTEE APPLICATION FORM
their
F:\CL=R\59LL\oFOrctd$'•.60ARD AND CU,a1MITTEES\6C Appii<oticn062509.tio<
.Have you ever been convicted of a felony: Yes ^ or No l ~lf yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ^ or Nod. If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ^ or No'S!I If yes, explain in detail
• Are you currently serving on any City Boards or Committees: YesYy or No ^. If yes; which board? ~ ` ~~
• What organizati//o~~ns itn~the City of Miami Beach do you currently hold membership in?
Name: 'YC l P~ Title:
Name: Title:
• List all properties owned or have an interest in, which are located wi hin the
1`toS w ~ ~ ~~ Ste- cv~6 ,-Ft.
of Miami Beach:
• I am now employed by the City of Miami Beach: Yes ^ or No~ Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ~, child C, brother ^, or sister ^ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): f~ rr-~
The following informatlon is voluntary and is neither part of your application nor has any beadng on your wnsideretlon for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Gender: ^ Male male
Ethnic Origin: Check one only (1)
^ White (Not of Hispanic Origin): All persons having origins in any of the odginal peoples of Europe, North Afdca or the Middle East.
^ Afdean-AmerieanlBlack (Not of Hispanic Origin): All persons having odgins in any of the Black radal groups of Africa.
~lispanie: All persons of Mexican, Puerto Rican, Cuban, Central or Soulh American, or other Spanish culture or origin, regardless of rece.
^ Asian or Pacgic Islantler: All persons having odgins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Pacific Islands. This area inGutles, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ American Indian or Alaskan Nadve: All persons having origins in any of fhe odginal peoples of North America, and who maintain
Culture) identification through tdbal affiliafion or community recognition.
Physically Challenged: Yes ^ or Nod.
Employment Status: Employed ~I Retired ^ Homemaker ^ Other ^
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying Gty personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the Gty (Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami
Beach Cdy Code section 2-26),
o Requirement to disGose certain financial interests and gifts (Miami-Dade County Code section 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 benefit from Community Development Blodc Grant funds for either yourself ,
or those with whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk
attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
- of the City Code "Standards of Conduct for City Officers Employees and Agency Memb ."
Please attach a copy ofyour resume to
on file for a pedod of one.(1) calendar,year.
Received in me City Clerk's Office by : ~~~ JI) . ~-~ Dat~0~Y~0p9 Control No. Date: _/ /2609