Tony RodriguezMIAMIBEACH
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Business Name:
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Professional License (describe)
CITY OF MIAMI BEACH
D COMMITTEE APPLICATION FORM
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Fax
City State Zip Code
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L.xpires: Attach a copy of fho Itcense
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; orb) 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 sbc (6) months: Yesx'or No ^
• Demonstrete an ownershipAnterest in a busine m Miami Beach for a minimum of six (6) months:-Ye>~or No ^
• Are you a registered voter in Miami Beach: Yes~Z' or No ^
• (Please i e one): I am now a resident of: North Beach South Beach ~ Middle Beach
• I am applying for an appointment because I have speaal abildies, knowledge and exp nce. Please list below.
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ~ or No~ ~=
HOME ADDRESS:
A t No.
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (31
choices will be observed by the Citv Clerk's Office (Regular Boards of City)
^ Affordable Housin Adviso Committee ^Housin Autho
^ Art in Public Places Committee ^ Loan Review Committee
D Beautification Committee ^ Marine Authori
D Board of Ad'ustment' ^ Miami Beach Commission for Women
ud et Adviso Committee D Miami Beach Cultural Arts Council
^ Ca ital Im rovements Pro ects Oversi ht Committee ^ Miami Beach Sister Cities P ram
^ Committee on the Homeless ^ Normand Shores Local Government Nei h, Im rovement
^ Committee for Quali Education in MB ^ Parks and Recreation Facilities Board
^ Commun' Develo ment Adviso ^ Personnel Board
^ Communi Relations Board ^ Plannin Board'
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indust Council
^ Desi n Review Board' ^ Public Safe Adviso Committee
^ Disabilit Access Committee ^ Safet Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
D ^ Sustainabili Committee
^ Ga Lesbian Bisexual and Tran ender GLBT ^ Trans arenc Reliabili 8 Arxauntabil' Committee "TRAC°
^ Golf Adviso Committee ^ Trans ortation and Parkin Committee
D Health Adviso Committee ^ Visitor and Convention Authori
^ Health Fadlities Authori Board D Waterfront Protection Committee
^ His anic Affairs Committee ^ Youth Center Adviso Board
^ Historic Preservation Board
`Board Required to File State Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
1. Past service on the Youth Center Advisory Board: Yes o 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, their
ages, and which programs. List below
Child's name:
Age: Program:
Child's name: Age: Program:
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.Have you ever been convicted of a felony: Yes ^ r No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes C or No . If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ^ or o o. If es, explain in detail
• Are you currently serving on any City Boards or Committee P / es or No ^. If yes; which board? .{-~
• What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Name:
• List all properties
Title:
an interest in, which are located within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes
• Pursuant to City Code Section 2-25 (b): Do you have a
City of Miami Beach? Check all that apply. Identify the depa
Which department?
spouse o, child ~, brother ~, or sister ^ who is employed by the
~~
The following information Is voluntary and Is nehher part of your application nor has any bearing on your consideration for appointment. It Is
being asked to comply with federal equal opportunity reporting requirements.
Gender: ale ^ Female
Ethnic Origin: Check one only (1)
^ White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ Af n-AmericanBlack (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
Hispanic: All persons of Mexican, Puerto Ricen, Cuban, Central or Soulh American, or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far Easl, Southeast Asia, the Intllan Subcontinent, on
the Padfc Islands. This area inGudes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ American Intllan or Alaskan Nadve: All persons having origins in any of the original peoples of North America, and who maintain
Cultural identification through tribal affiliagon or community recognition.
Physically Challenged: Yes oo.
Employment Status: Employe2}~1 Retired ^ Homemaker ^ Other ^
NOTE: ff 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 city personnel (Miami Beach City Code section 2-059).
o Prohibition from contracting with the city (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 City Code section 2-26).
o Requirement to disclose 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 Block Grant funds for either yourself ,
or those with whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these Taws may be obtained from the City Clerk.
"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 OiFlcere, Employees and Agency Members."
Please attach a copy W your.resume to this applicatlon
NOTE: Applicetlons will remalh qn nle for a period of one (f) calendar year.
Received in me City Clerk's Office by : Date: _/ /2009 Conbol No. Date: /_/2009
Name of Deputy Clerk