Gabriel Paez j
---- M BEAC H CITY OF MIAMI BEACH
�%�/��� BOARD AND COMMITTEE APPLICATION FORM
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NAME: 1' ‘6,_5 (z) a L
Last First Name / iddle Initial
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HOME ADDRESS: l � (./ �/ fi D � Cjj L 3 $ r yi /d'N/ - 0 cac.. R 33 r
Apt No. . House No. /Street City State Zip Codel
PHONE: Ot t o U
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me iJ 1\f s r � Work Ai _ ` � Fax Email address
Business Name: ` -5- f i " Position: E� �`
Address: 9 0 [P S M an -w► i 6 C- ti r 3 3 1)
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; th
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 ' mum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) mon hs: Yes r No 0
• Demonstrate an ownership /interest in a business in iami Beach for a minimum of six (6) months: Yes ❑ or No ga-
• Are you a registered voter in Miami Beach: Yes or No 0
• (Please circle one): I am now a resident of: North Beach Middle Beach
• I am appl 'ng for a ointment becaus I have speciajy� bilities, knowle and expen ce. Please list below:
7 D r n— ., iv, Ai,. K ee vVr-
• Are you resen Y tl a re 9 lobbyist City istered lobb ist with the Cit of Miami Beach? Yes
Y o
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
0 Affordable Housing Advisory Committee 0 Marine Authority
❑ Art in Public Places Committee 0 Miami Beach Commission for Women
❑ Beautification Committee 0 Miami Beach Cultural Arts Council
❑ Board of Adjustment* 0 Miami Beach Human Rights Committee
❑ Budget Advisory Committee 0 Miami Beach Sister Cities Program
❑ Capital Improvements Projects Oversight Committee ❑ Normandy Shores Local Government Neigh. Improvement
❑ Committee on the Homeless ❑ Ppn4Cs and Recreatio Facilities Board
❑ Committee for Quality Education in MB aa7ning nnel Board
❑ Community Development Advisory , Board* c
0 Community Relations Board 0 Police Citizens Relations Committee
❑ Convention Center Advisory Board ❑ Production Industry Council
❑ D rment Committee 0 Public Safety Advisory Committee
esign Review Boarc* 0 Safety Committee
❑ Disability Access Commi' =e - 0 Single Family Residential Review Panel
❑ Fine Arts Board 0 Sustainability Committee
❑ Gay, Lesbian, Bisexual and Transgender (GLBT) 0 Transportation and Parking Committee
0 Golf Advisory Committee 0 Visitor and Convention Authority i
0 Health Advisory Committee 0 Waterfront Protection Committee ,
0 Health Facilities Authority Board ❑ Youth Center Advisory Board
❑ Hispanic Affairs Committee
❑ Historic Preservation Board
0 Housing Authority
❑ Loan Review Committee *Board Required to File State Disclosure Form
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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 0 No ❑ Years of Service:
2. Present participation in Youth Center activities by your children Yes❑ No 0. 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 D or No If yes, please explain in detail:
• Do ou current) have a violation(s) of City of Miami Beach codes: Yes D or No . If please explain
y y O y es y, p in detail:
• Do you currently owe the City of Miami Beach any money: Yes ❑ or No If yes, explain in detail
• Are yo urrently serving on any City Boards or Committees: Yes r No D. If yes; which board?
&( tiCL Bo iiI
• What organizations in the ity of Miami Beach do you currently hoI membership in?
Name: e,t r Z/.• ce 14de yFt 41 ` U #f itie: Cr I� tf ! It li 4-
Name: Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
ND 1 GoLs�-/ ' t _ . f t w ' f l o 3 , 6 , i 3 ) 3 j ,
• I am now employed by the City of Miami Beach: Yes 0 or N hich department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse ❑, child 0, brother 0, or sister 0 who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
The following infor ion is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. I t is
being asked to co ply with federal equal opportunity reporting requirements.
Gender: ile • ❑ Female
Ethnic Origin: Check one only (1)
❑ Whi (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
❑ ican- American /Black (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
ispanic: 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 Retired ❑ Homemaker ❑ Other ❑
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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 disclose certain financial inter 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.
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"I - eby atte to t, a accu - = cy a • truthfulness of the application and have received, read and will abide by Chapter 2,
A isle VII — o ' he • ty - : .. 1 dards of Conduct for City Officers, Employees and Agency Members."
Applicant' - Signatur- t Date Name of Applicant (PLEASE PRINT)
Please attach fa copy of your resume to this application
NOTE„ Applications will rem ` "non f fora period of one >year
via /,e2
Received in the City Clerk's Office by : r / Dater /201 Control N liOt Date. / 01
Name of Deputy Clerk
0 MIAM IBEACH
City of Miami Beach,
1700 Convention Center Drive, ,
Miami Beach, Florida 33139,
www.miamibeachfl.gov •
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254 -
Acknowledgement of fines /suspension for Board Members for failure to comply with Miami
Dade County Financial Disclosure Code Provision Code Section 2- 11.1(i) (2)
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Board Member name: A 6 - Re-L,
I understand that no later than July 1, of each year all members of Boards and Committees of the City of
Miami Beach, including those of a purely advisory nature, are required to comply with Miami -Dade County
Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary
responsibility is to recommend legislation or give advice to the City Commission, must file, even though you
may have been recently appointed.
You must file one of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida, by July 1 each year.
1. A "Source of Income Statement" (attached) or
2. A "Financial Statement" (attached( or]
3. A Copy of the person's current Federal Income Tax Return
Failure to file, according to the Miami -Dade County Code Chapter 1, General Provision,
Section 1 -5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment
in the county jail for a period not to exceed sixty days, or both.
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Signature: Date:
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