Baruch Sandhausm MIAMI BEACH
NAME:
HOME ADDRESS:
Last Name ,
PHONE: '>r'D6'~s~ '~
Home
Business Name:
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Address:
No.
Professional License (describe) _
Pursuant to City Code section 2-2:
requirement shall be fulfilled in the
months; or b) an individual shall dem
• Resident of Miami Beach for a mini
• Demonstrate an ownership/interest
• Are you a registered voter iri Miami
• (Please circle one): I am now a resi
• I am applying for an appointment b~
• Are you presently a registered lobb
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Name
City
Middle
Zip Code
ax Email address
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City State Zip Code
Expires: Attach a copy of the license
I a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
owing ways: a) an individual shall have been a resident of the city for a minimum of six
~trate ownership/interest for a minimum of six months in a business established in the city.
im of six (fi) months: Yes C'or No ^
a business in Miami Beach for a minimum of six (6) months: Yes ~'or No ^
:ach: Yes ^ or No ^
nt of: North Beach South Beach fiddle Beach
fuse I have special abilities, knowledge and experience. a ow:
t with the City of Miami Beach? Yes ^ or No B'
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three f3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
^ Affordable Housin Adviso Committee ^Housin Authori
^ Art in Public Places Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Autho '
^ Board of Ad'ustment" ^ Miami Beach Commission for Women
^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council
^ Ca ital im rovements Pro'eets Oversi ht Committee D Miami Beach Sister Cities Pro ram
^ Committee on the Homeless ^ Normand Shores Local Government Nei h. Im rovement
^ Committee for Qual' Education in MB ^ Parks and Recreation Facilities Board
^ Communit Develo ment Adviso ^ Personnel Board
^ Commun' Relations Board ^ Plannin Board"
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Pr coon Indust Council
^ Desi n Review Board" ^ lic Safet Adviso Committee
^ Disabil' Access Committee afe Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabili Committee
^ Golf Adviso Committee ^ Trans arenc Reliabili 8 Accountabil' Committee "TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Autho ' .Board ^ Visitor and Convention Autho '
^ His anic Affairs Committee ^ Waterfront Protection Committee
^ Historic Preservation Board ^ Youth Center Adviso 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 Yoat)•r ~_~,e,jp!tojj c~visory+B~oaKt' Y ~ Nq ~ Years of Servic:~:
2. Present participation ih 1~oGftt ~Ce~i:~i`activities'by ~oUr childrbn 1"es^ No ^. tf yes, pleas~;l~$t]t#~(~ r~rio`e`s ~if~ybu~ ~iairen, their
ages, and which programs. List below: ~
Child's name: Age: Program: __ ~ r+ .nr ttH~~n-~ o~oZ
Child's name:
Age: Program:
F:\CLER\$ALl\aFORMS\BOARD AND COMMITTEES\BC ApplicationOG2609 NEW.doc
S~
.Have you ever been convicted of a felony: Yes = or~- If yes, please explain in detail:
• Do you currently have a violation(s) of L'1 tami Beach codes: Yes - or I~io ~. If y~y~~d~s~eilain in detail:
G ~ ~'Y
• Do you currently owe the City of Miami Beach any money: Yes ~ or 1~o C. If yes, explain in detail
J ~w
• Are you currently ~ rvi ~~r ,br~C,ii~ ~~ards or,~p~~itte~~ eY~~~gr ~, ~,If,v~s~uh 6~aar~?
• What organizations in the City of Miami Beach do you currently hold membership in~~ M r i
Name:
Name:
Title:
Title:
. List all properties owned or have an interest in, which are located within the City of Miami Beach:
. I am now employed by the City of Miami Beach: Yes ^ or 6~ Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ~, child ~, brother q or sister ~ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
The following Information is voluntary and is nekher part of your applicatfon nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Gender: C~Male ^ Female
Ethnic Origin: Check one only (1)
{~Whlte (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-AmericaNBisck (Not of Hispanic Origin): All persons having origiris in any of the Black radal groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
^ Asian or Pacific Islander: All persons having origins in arty of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Padfic Islands. This area indudes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain
Cultural identfication through tribal affiliati/on or community recognition.
Physically Challenged: Yes ~ or No3.
Employment Status: Employed ~ 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 city personnel (Miami Beach City Code section 2-459).
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 he a t the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
A le I o City Code "Standards of Co duct for City Officers, Employees and Agency Members."
~ eN sta~~t~4~s
App cant' ure ate Name of Applicant (PLEASE PRINT)
N~Df ::rApp~tlcations-Wlll+remaip~on~,flle~;for:a period of:one (1):calendar year.
Received in the City Clerk's Office by : "" ~l~X~f li Date: _I 1 10 Control
Name of Depu Clerk F:ICLER~$ALL~aFORMS~BOARD