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Anthony Japour LEA M 1 AM ( B EAC H CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLIC ON FOFiM NAME: 2 ;17 9 b*& AA/ nti, �! ` Last Name • 30D ? First Na n ,( � ,,, / , Mi dle Initial HOME ADDRESS: ! 2D 2/' 5 `' �'� t"'e- IJ V v I( /' x��� L Apt House No. /Street Ci • State Zip Code PHONE: �• ! • a ) pt I) ' 1 .i t / . Home Work F -x E 6t•dr ss L Business Name: d , / .. )V 7 e . 7 2 7 ‘ Position: :, Address: 1 Al tom . ./ . 4 LJ -3 1 ) No. Stree ity State Zip Code ; Professional License (describe) Expires: :, •. -- - Attach a dopy 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: Yes or No 0 • Demonstrate an ownership /interest in a business in Miami Bea for a minimum of six (6) months: Yes* or No ❑ • Are you a registered voter in Miami Beach: Yes 0 or No ❑ i • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am appl ing for an a pointm nt because s I c of iami ea i aabili ' s, kn wle e and perience. Please list below: te • Are r s t � ist l obhi wi tfi Petty h 9 Y c .Yes ❑ or No I>t k14.4 !rl GIiS Please list your preferences in order of ranking [1] fir t choice [2] second choice, and [3] third choice. Please note that only thre (3) choices will be observed by the City Clerk's Offic i (Regular Boards of City) 0 Affordable Housing Advisory Committee 1 0 Marine Authority *Art in Public Places Committee 0 ❑ Miami Beach Commission for Women ` 0 Beautification Committee 0 Miami Beach Cultural Arts Council 0 Board of Adjustment* 0 Miami Beach Human Rights Committee O Budget Advisory Committee 0 Miami Beach Sister Cities Program 0 Capital Improvements Projects Oversight Committee ❑ Normandy Shores Local Government Neigh. Improvement , ' ❑ Committee on the Homeless I ❑ Parks and Recreation Facilities Board , ❑ Committee for Quality Education in MB 0 Personnel Board 0 Community Development Advisory 0 Planning Board* 0 Community Relations Board ❑ Police Citizens Relations Committee 0 Convention Center Advisory Board 0 Production Industry Council b ❑ Debarment Committee ❑ Public Safety Advisory Committee 0 Design Review Board* 0 Safety Committee ❑ Disability Access Committee ❑ Single Family Residential Review. Panel ! 0 Fine Arts Board ❑ Sustainability Committee ❑ Gay, Lesbian, Bisexual and Transgender (GLBT) 0 Transportation and Parking Committee ❑ Golf Advisory Committee 0 Visitor and Convention Authority • Health Advisory Committee 9 0 Waterfront Protection Committee ❑ Health Facilities Authority Boar 0 Youth Center Advisory Board ❑ Hispanic Affairs Committee 0 Historic Preservation Board 0 Housing Authority ❑ Loan Review Committee *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 ❑ No 0 Years of Service: 2. Present participation in Youth Center actwwities by your children Yes❑ ',No 0.. If yes, please list the'names' of your children, their ages, and which programs:List Child's name: Age: Program: Child's name: Age: Program: 1 F: \CLEER \$ALL \a FORMS \ BOAR D AND COMMITTEES \BC Application.doc 4 li •Have you ever been convicted of a felony: Yes ❑ or No /f yes, please explain in detail: • • • Do you currently have a violation(s) of City of Miami'Beach codes: Yes ❑ or No ®!If es , please explain lain in detail: Y P • Do you currently owe the City of Miami Beach any money: Yes ❑ or No [9 . If Y Y yes, explam detail , • Are you currently serving do any ity Boairds or ommittees: Ye or No ❑•. If yes; which board? ' S • 11111idM''S • What organizations in the City of Miami Beach do you currently hold membership i ? Name: jd Title: Name: 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 'CI or Noe. Which department? • Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister ❑ who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): • • The following information is voluntary acid is neitherpart 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: �l Male ❑ Female Ett,tc Origin: Check one only (1) hite (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 the Black racial 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 any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on the Pacific Islands. This area includes, 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 identification through tribal affiliation or community recognition. Physically Challenged: Yes ❑ or No❑. Employment Status: Employed 1 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 laws 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, Articl II of City Code "Standards of Con ct for City Officers, Employees and Agency Members." (11 Applicant' ig ure Date Name of Applicant (PLEAS P RINT) Please attach a copy of your resume to this application NOTE: Appli do s will re in on fi for a.period of ne (1)' alendar year. Clerk's Office b 7, ' 1 q 0 Received in the Cit Y Y Date: /2010 ontrol No. P ) Dat /2010 Name of Deputy Clerk