Jack Benveniste
NAME:
~~ ~~ I~/~`~t~,C~
.fie ~~.~
CfTY OP MIAMI 3cACH
BOARD AND COMMiTii EE APPLICATION PCRN;
a(s~,Name ~~ =first Nama p~ IJ~lodle Ini4al
HOME ADDR°_SS: ~(/ ~S y/"Q~~~/~G-' ~ / ~ ~ ~ ~~~~
PHONE:
Apt No. House Na/Street City State Zip Code
Home ) Work i
Business Name:,~L~~~R.IJ.v~ ~ D/IiGS Position:
Address:
~3
No. street ~rry State Zip.Gotle
Professional License (tlescntre) ~ ~J1 F~~ .~ ~~~~ Ezpires:__ ///~/Z grreoh a copy o/the license
Pursuant to City Code section 2-22(4) a and h: Members of agencies, boards, and committees shall be affiliated wRh the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have bean a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city,
. Resident of Miami Beach for a minimum of six (6) months, Yes ^ or No ^
. Demonstrate an ownershiplirrterest in a business in Miami Beach for a minimum of six (6) months: Yes ^ or No
. A2 you a registered voter in Miami Beach: Yes ^ or No ^
. (Please arcfe one): 1 am now a resident of: North Beach Sottth Beach Middle Beach
. I am applying for an appoinfinerrt because I have special abilities, knowledge and experience. Please list below:
. Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No ^
Please list your preferences in order of ranking (1j first choice (2j second choice, and [3j third choice. Please noffi that only three r31
chokes will be observed by the City Clarks {?Rice. (Regular Boards of City)
D Affordable Housin Adviso Committee D Housin Autho
D Art in Public Places Cmnmltiae ^ Loan Review Committee
^ Beautification Committee ^ Marine Autho
D Board Ad trstmertP D Miami Beach Commission for Women
t Advffio Committee ^ Miami Beach Cultural Arts Catrndl
D C iffiI Im vramertts girds Dvers ht Committee ^ Miami Beach Sister Cities P
D Committee an the Homeless D Norman Shores Local Govemmem Ne h. 1 ant
D Committee for Qual Education in MB D Parks and Recreation Faclltties Board
^ Gommun bevel mem Adviso D Personnel Board
D Commun Relations Board p Ptannin Begirt'
^ Convention Center Advil Board D Police Citizens Relations Committee
D Debarmem Committee D Production tndu Council
^ Desien Review Begirt' D Public S Advise Committee
^ Disabll Access Committee D Sa Committee
^ Fine Arts 8oart p Sin le Famtl Residerrtial Review Panel
^ Ga .Lesbian, Bisexual and Transoender GLBT ^ Sustainabll Committee
^ GoL` Advis Commtttae D Tra aren Reliahil & AccourrtabiltN Committee 'TRAC"
^ Heatth Advso Committee D Tra ortation and Parkin Committee
^ Heatth Factittties Atttho ' Boart D Vrsttor and Converrtion Atrtho
^ His nic Affairs Commitee D Waterirom Protection Commltme
^ Historic Preservation Board ^ Yottth Comer Adviso Beard
"Board Required to Flle State Disclosure Fonn
Note. If applying for Youth Advisory Board, please indicate your affiliation vrith the Scott Rakow Youth Center
5. Past service on the Youth Center Advisory Board Yes . No G Years of Service
2 Preserr perticlpation in Youth Center activities by your children Yes_ Nc _. If yes, please list the names of your children, their
ages, and which programs. Lrst below
Childs nam=~
Cnild's nam=_
Age: Program.
Hge. Program:
,.!.P.54!'. ~a`DRM,$\8~4P,D AND ~OMMI1T:Ei ~B: A~oi¢ouonDG260~ N°_~'.oo:
~~.
•-7ave yo~_ eve- :,ear co,vr_t=_ e ia~.on:~ "es ~v>s e
oleasa zolalr. in oe;air
• ~o you ourrently nave a vlo;atlorns, of C¢y of lJuam. 5eacF codes Yes . o~.P(t~ I` vas oisasa ero;alr a Dalai!
. Do you currently owe fr,e City o' lt4iam; Brach any money Yes . or Nowes ezolarn u• detail
• Ore you currently servm~ or and ~It~ 3oards or ~ommine>s Yes oryici'I` vas w~ior ooard~
• VJhat oryani~ationsJr~he ;,itq o'' Miami 3eacn ac you purr=ntly noio memoersnl,. lnr
Name. //~ ~1/L- -itie
Name
• List all
or have an interest in, which are located with n the City of Miami Beach:
. I am now employed by the City of Miami Brach: Yes ~ or No~. hich deoartment?
. Pursuant to City Code Section 2-25 (b): Do you have a parent D, spouse D, child G; brother D, or sister D who is employee op tne~
City o` Miami Beach % ChecY. all that app)}•. Identify the department(s):
Tne following information Is voluntary entl Is neltlter pert of your applicaflon nor has any bearing on your eonsitleretlon for aopolntmen: P, ~t
oeing asked to comp) tth federal equal opponanity reporting requlremems.
Gender: ale ^ Female
on=_ only (~
~fike (NOi of Hispanic Drigin}~. All persons having origins in any of the original petioles of Europe, North Afr'ice or the Middle East
^ Afrf~n-AmerieanlBlaek (Not of HlspeMc Ohgln): All persons having origins in any o' the BIacY. 2r7a1 group6 of Africa.
Hieoenfc All persons of Meziwn. Puerto Rican, Cuban, Cerdral or Sotrth Amenoan, or other Spanlah :allure or origin, regardless of race
:J Asian yr Paetffc launder: All persons Raving ttrigrtts in any of the original peoples of the Far East SoNheast Axle, the Indian Subwntinen:. or
the Pedfic islands. Tads area incomes, for laample, China, Ind2. Japan, Korea, the Philippine Islands entl 3omoa.
J Amaneen Indian yr Alaefran tietlve: Ail parsons having origins in any of the original peoples of North Arrreriea, end who maintain
Crrlwraf idarrtifieafion through tribal atflllafltin or mrrtntttrdty recopnttion
Employment Status.
Ye8 ] Or NOD.
Retired ^ Homemaker ^ Cther p
NQTE: If appoitrted, you will be ragttired to fofiow certain taws which appty to ally boardfeommltiae membaes.
These iavvs ineiude, but ate not IimMed hl, the following:
c Prohibition from directly ar indirectly lobbying cit}' personnel (IJrlami Beach Chy "ode section 2-459}
., Prohibition from contracting wfth the dty (Miemr-Dade County Code section <^-11.1 }
o Prohibition from lobbying before baaniJCOmmtttae you have served on for period of one year after leaving office (Mlarr
Brach City Code section 2-26).
Raquiremert[ to disdose certain finandal interests ono gifts (Mlam~-Dade Coumy Code secion 2-1 i.1 ).
ire: CMB Community Development Advisory Committae)~ prohibition, during tenure and for one year after Issuing ofil.^e
from having any irttarest in or receiving any beneftt fmm Communty Developmern Block Grant funds for either voursel'
or those with whom you have buamass or immediate family ties (C=R 7D.611 }.
Upon request, copies of these Yaws may be obtained from the Chy Clerk..
Hereby attest to the accuracy and truthfulness of the application and have received, read anC will abide by Chante~ ;
~rtic ~ I - of the Clty Cotle "Standa~~Cpntluct for Cit}~ officers, Emoloyeas and Agencny Members."
°lease 8ttaeh a COOS' o' v°ur resume to tins epnifcebon
NOTE: Ao heanons will reymem on file for n xenon of one f1 i Celenaer veer
Recewec ir. the ;rt~~ ~iencs. ;7riire oy _ . _ //!'' Gate -?' 0 ~~ :,ontroi Nc
Gate ~L;~ / ~ `