Carol Ann Housen Sia- MIAMI BEACH
Y BOARD AND COMMITTEE A U A ON FORM
- iAMtE: / • 5 .
Last Name .---pi. V
HOME ADDRESS: �DO! First Name Middle Initial
X330 ii ,t 3
Apt No. House No. /Street ��� . ' • /y/
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PHONE: Q ; � � � �, City State Zip Code
Home Work ' � , (o f?' 93 ■ d/'
Business Name: , r/ .- I . 9∎I Fax / Email address �
• osition: A , / ! � /�a i �
Address: , • " . e o e s ,
No. / Street
Professional License (describe) / . ` - City State Zip Code
Cd ri /O i Expir esAftach 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 shall have been 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: Yeor No ❑
• Demonstrate an ownership /interest in a business in MiarrV §each for a minimum of six (6) months: Yes 3 or No ❑
• Are you a registered voter in Miami Beach: Yes ❑ or No
• (Please circle one): I am now a resident of: ,?( North Beach South Beach
• I am applying for an appointment because I have special bilities, nowledge n ex•erience. Please list below: /( •7'a f
much cou)s1' - oP � � c Middle Beach
• Are you presently a registers lobb ist with a C'ty of Mi Yes p " or ' No + , ; sG /4n. � /
e a t . , �%1� V' / ' , r ' ;
,1 is S i
Please list your preferences in order of ranking [1] first ch [2] second choice, and [3] third choice. , , C etar
choices will be observe b the CI Clerk's Office. (Regular Boards of City) Please note that only three f3
❑ Affordable Housin• Adviso Committee
❑ Art in Public Places Committee ❑ Housin. Authori
❑ Beautification Committee ❑Loan Review Committee
❑Marine Authori
❑ Board of Ad'ustment*
❑ Bus •et Adviso Committee._ __- ❑_Miami Beach Commission -for Women --
- -- ❑ Ca..tal Im.rovements Pro'ects Oversi•ht Committee ❑ Miami Beach Cultural Arts Council
❑ Committee on the Homeless 0 Beach Sister Cities Pro. ram
❑ Committee for the H Education in MB ❑ Normand Shores Local Government Nei. h. Im • rovement
❑ Parks and Recreation Facilities Board
❑ Communi Develo.ment Adviso
❑ Communi Relations Board ❑Personnel Board
❑ Convention Center Adviso Board ❑ Plannin • Board*
❑Debarment Committee ❑ Police Citizens Relations Committee
-_, Desi•n Review Board* ❑Production Indust Council
❑ Disabili Access Committee ❑ Public Safe Adviso Committee
❑ Fine Arts Board ❑Safe Committee
❑ Sin • le Famil Residential Review Panel
❑ Ga ,Lesbian, Bisexual and Trans. ender GLBT
❑ Golf Adviso Committee
❑ T ❑ Sustainabili Committee
rans.ortafion and Parkin. Committee -.K -
•
❑ Health Adviso Committee o
❑ Health Facilities Authori Board ❑ Visitor and Convention Authori
❑ His •anic Affairs Committee ❑Waterfront Protection Committee c--)
•
❑ Historic Preservation Board ❑Youth Center Adviso Board
11111 111111111111 Required to File State Disclosure F • m
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Yo •�
uth •
Center: rV
co
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❑ Nb D. If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: t
Age: Program:
Child's name:
Age: Program: _______..___________ /4
\CEEB` „ALL \oFORM S`ZBOARD AND COMMITTEES \BC Applicatian062604 NE\W.. oc
•Have you ever been convicted of a felony: Yes or o If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes o m- If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes o If yes, explain in detail
• Are you currently serving on any City Boards or Committees: es or No If yes; which board?
,C/ uL R rs . 15 ch /
• What organizations in the City of Miami. Beach do you currently hold membership in ?�i
7 f Title: 6 f i e) �G! PiJLf
Name: _ C �� i .C _ .Q v' v �I7 / f� O d
�� i / /c_!
Name Title:
• List all properties wned or have an interest in, which are located within the City of Miami Beach:
3 "r ' -2c)c)c ins X57 j i5 - 6 75 7 "
• I am now employed by the City of Miami Beach: Yes ❑ o Non'. hich department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent C, spouse D, child 0, brother 0, or sister ❑ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ) 1 q
The following information is voluntary and is neither 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: 0 Male
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.
❑
African-American/Black (Not of Hispanic Origin): All persons
having origins in any of
American, the Black racial groups
Spanish culture orooriginaregardless of race:
❑ Hispanic: All persons of Mexican, Puerto Rican, Cuban, C
❑ Asian or Pacific ds s includes, for example, ChinaYlndiaQJapanaKorea!the Philippine Southeast
Somoia, the Indian Subcontinent, on -
the Pacific Is
❑ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain
Cultural identification through tribal affiliation or community recognition.
Physically Challenged: Yes ❑ or Nq
Employment Status: Employes r. Retired ❑ Homemaker ❑ Other ❑
NOTE: If appointed, you will be required to follow certain laws which apply to city boardlcommittee 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).
fro: rom h v Com aving any in est i receiving any benefit from Community Development Block for one year Grant funds for either yourself ,
f hn
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.
"I hereby attest to the accuracy and truthfulness of the i application and have
ve r c Agency Members."
will abide by Chapter 2,
Article VII — of the Code "St. ndards Conduct for ty 6 ' d )U
Applicant's Signature
�� Date Name of Applicant (PLEASE PRINT)
resume to this application
of your re
Please attach a copy y NOTE: Applications will remain on file for a period of one (1) calendar year.
Date: _I !2010 Control No.
Date: _1
Received in the City Clerk's Office by : Name of Deputy Clerk F: \CLER \$ALL \aFORMS \BOARD AND COMMITTEES \BC Application.doc