Claire Warren
NAME: U / I /~-'-'~-~ ~ i
L05 d
HOME ADDRESS:
Apt No.
PHONE: ~~ _ ~~~G
Home
Business Name:
CfTY O'r MI~,NII BEkCi-d
RG AhID COMMfTTEE ,4P?LIC,~.TIOh i=OP.N
Name
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House No.lStreet
Work
Fax
Middle Initial
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Citrn~y ~~i~/~ //'~ ~~ QState Zi ~Co~d
f=mail address
Position:
Address:
No. Street City State Zip Code
Professional License (describe)
Expires' 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 sh II have been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownership/interest fora Inimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of sa (6) m s: Yes ~ r No 0
• Demonstrate an ownership/interest in a business i iami Beach for a minimum of si ~(6) months: Yes D or No
• Are you a registered voter in Miami Beach: Yes or No D
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I am appiyin ran ~p 'n'nltment becau~se~I eve spedal ab'lities, kno~fedge~,ar~d a erience. a ~s low:
Y P~~ ~yi5~ ~~® ~ '"'rzn ~i~ ~ ~~~C/ mac- ff~
• Are ou s y ~re re obb Est e C Mtami Beach? Yes 0 or N D
Please fist your preferences in order of ranking [1J first choice [ZJ second choice, and [3) third choice. Please note that oniv three ~3)
choices will be observed by the City Cleric's Office. (Regular Boards of City)
D ffordable Housin Adviso Commtttee D Housin Autho
Art in Public Places Committee D Loan Review Committee
Beautification Commtttee D Marine Autho
D Board of Ad'ustmertt' D Miami Beach Commission for Women
D B Ad ' Committee ~ Miami Beach Cultural Arts Coundl
D C itel im rovemerrls P 'acts Oversi ht Committee D Miami Beach Sister Cities Pro ram
D Committee on the Homeless D Normand Shores Local Govemmerrt Nei h. im rovement
D Committee for Qual' Education in MB D Parks and Recreation Facilities Board
D Commun Devefo ment Adviso ^ Personnel Board
D Commun Relations Beard D Plannin Board'
D Convention Center Adviso Board Pofioe Citizens Relations Committee
D Debarment Committee D Production indu Council
D Desi n Review Board" ubiic S Adviso Committee
D Disabii' Access Committee D Sa Committee
D Fine Arts Board D Sin le Famif Residential Review Panel
D Ga ,Lesbian, Bisexual and Transaender GLBT D Sustainabil' Committee
^ Golf Adviso Committee ^ Trans wren Reliabil' 8 Accountabil' Committee "TRAC"
^ Health Adviso Committee ^ Tcan ortation and Perkin Committee
D Health Fadvities Autho ' Board D Visitor and Convention Atrtho '
D His nic Affairs Committee D Waterfront Protection Committee
D Historic Preservation Board ^ Youth Center Adviso Board
"Board Required to Flle State Disclosure Form
a
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 ~ No ~ Years of Service:
2. Present participation in Youth Center activities by your children Yes_~ No ~. If yes, please fist the names of your children, their
ages, and which programs. List below:
Child's name:. Age: Program:
Child's name:
Age: Program'
='\; L~P'.SAL!'\a~~RMS\B~ARG AND ~OMMITT~E~\B:. ADplicoiion062604 N.V~'.do:
•~iave you aver Deer canvicteC c` s relonv Yes NO I` ves. please explain in detail:
• Do you currently have a vroiation(s) o? City of Miami Beach codes. Yes ~ ~x~fio ~. It yes, please erpiain it detail:
• Do you currently owe the City of Miami Brach any money: Yes . ~No ~. If yes.. explain in detail
• Are you currently serving on any City Boards or Committee: Ye or No -. I` yes, whict board
. What organizations in the~C/ii~ ?Miami Beach do you currently hold membership ln?
Name: /"~f~--` Title:
Name: Title:
• List all propert~s owned or have an interest in, which are located within the City of Miami Beach:
• I am now ernpioyed by the City of Miami Brach: Yes ~~ or No~lWhich department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent D, spouse C~, hild G, brother G, or sister D who is employed b~~ the
City of Miami Beach? Check all that apply. identify the department(s): „ .,,
The following information is voluntary and !s neRhar part of your application nor has any bearing on your consideration for appointment. tt Is
being asked to comply with federal equal opportunity repotting requirements.
Gender: 0 Male male
one onry (1)
~ White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-AmertcanBlack (Not Of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
Htepanic: All persons of Mexican, Puerto Rican, Cubes, Cetrtral or South American, or other Spanish culture or origin, regardless of race.
U Arlan or Pacific lslandec: All parsons having origins in any of the original peoples of the gar .asi, Sotrtheast Asia, the Indian Subcorifineni. or
the Pacific tsfands. This area includes, for exemP~, China, India, Japan, Korea, the Philippine Islands and Somoa.
J American inciiian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain
Cultural iderttlficafion through tribal atflliation or ity recogMtton.
Physically Ckalienged: Yes D or No
Employment Status: Employed 0 Retired~d~Homemaker ^ Other p
NOTE: If appointed, you wIl! be required to follow certain caws which apply to city boardfcommitbae members.
These laws include, but are not limffosd to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracEing 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 (Mlam~.
Beach City Code section 2-26).
o Requirement to disdose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Commtttee): prohibition. during tenure and for one year after leaving office
from having any interest in or receiving any benefit from Communit)~ Development Block Grant funds for either yourself
or those with whom you have business or immediate family ties (CFR 57D.611).
Upon request, copies of these taws may be obtained from the City Cteri;.
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter ~.
Artic I - of the i Code "Standards of C nduct for City Officers, Employees and Agency Members."
Applicarrt`s Signature ~ a Name o. Hpplicanl (PLcASE pRINT1
Please attach a copy of your resume to this application
NdTE: Applications will remain on file for a period of one (1) calendar year.
Receroed rn the City Clerk's Gffrce v)' Gate- _' /2005 :;ontroi No
Name of Ueptriv Clerk
Gate /2005