Brent Coetzee Application (2)
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
NAME:
Coetzee Brent
Last Name First Name Middle Initial
HOME ADDRESS:
11 m
5055 Collins Ave Miami Beach FL 33140
Apt No. House No./Street City State Zip Code
PHONE: 305 798 - 7002 305 673 - 3354 brent - coetzee@msn.com
Home Work Fax Email Address
Business Name: Roasters 'n Toasters Position Owner
:
Address: 525 Arthur Godfrey Rd Miami Beach FL 33140
No. Street City State Zip Code
P rofessional License (describe) : Real Estate Broker Expires: 11/30/2011 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 shall have been a resident of the city for a minimum o f six
months; or b) an individual shall demonstrate ownership/interest for a minimum of six months in a business establi shed in the city.
● Resident of Miami Beach for a minimum of six (6) months: Yes
● Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes
● Are you a registered voter in Miami Beach: Yes
● (Please circle one): I am now a resident of: Middle Beach
● I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
Travelled internationally teaching tennis prior to becoming a property and business owner in Miami Beach.
● Are you presently a registered lobbyist with the City of Miami Beach? No
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)
Affordable Housing Advisory Committee Marine Authority
Art in Public Places Committee Miami Beach Commission for Women
Beautification Committee Miami Beach Cultural Arts Council
Board of Adjustment* Miami Beach Human Rights Committee
Budget Advisory Committee Miami Beach Sister Cities Program
[1] Capital Improvements Projects Oversight Committee Normandy Shores Local Gov’t Neigh. Improvement
Committee on the Homeless Parks and Recreation Facilities Board
Committee for Quality Education in MB Personnel Board
[3] Community Development Advisory Planning Board*
Community Relations Board Police Citizens Relations Committee
[2] Convention Center Advisory Board Production Industry Council
Debarment Committee Public Safety Advisory Committee
Design Review Board* Safety Committee
Disability Access Committee Single Family Residential Review Panel
Fine Arts Board Sustainability Committee
Gay, Lesbian, Bisexual and Transgender (GLBT) Transportation and Parking Committee
Golf Advisory Committee Visitor and Convention Authority
Health Advisory Committee Waterfront Protection Committee
Health Facilities Authority Board Youth Center Advisory Board
Hispanic Affairs Committee
Historic Preservation Board
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: No Years of Service:
2. Present participation in Youth Center activities by your children No 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:
● Have you ever been convicted of a felony: If yes, please explain in detail:
● Do you currently have a violation(s) of City of Miami Beach codes: Yes If yes, please explain in detail:
an open permit in restaurant
● Do you currently owe the City of Miami Beach any money: No If yes, explain in detail
● Are you currently serving on any City Boards or Committees: No If yes; which board?
● What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
● List all properties owned or have an interest in, which are located within the City of Miami Beach:
5055 Collins Ave #11m, 5055 Collins Ave #11L
● I am now employed by the City of Miami Beach: No Which department?
● who is employed by the
Pursuant to City Code Section 2 - 25 (b):
Do you have a
City of Miami Beach? Check all that apply. Identify the department(s):
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: Male Race: White
Ethnic Origin: Check one only (1)
White
Physically Challenged: No
Employment Status: Employed 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:
P rohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2 - 459).
o
P rohibition from contracting with the city (Miami - Dade County Code section 2 - 11.1).
o
P rohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami
o
Beach City Code section 2 - 26).
R equirement to disclose certain financial interests and gifts (Miami - Dade County Code section 2 - 11.1).
o
(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 Cl erk.
“I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII – of the City Code “Standards of Conduct for City Officers, Employees and Agency Members.”
I Brent Coetzee agreed to the following terms on 1/13/2011 3:00:53 PM
Please attach a copy of your resume to this application
NOTE: Applications will remain on file for a period of one (1) calendar year.
Received in the City Clerk’s Office by: __________________ ______ _______ Date: _ _ _/ __/____ Control No. __________ Date: _ __/__/_____
Name of Deputy Clerk