Raymond Adrian Board Application c---it- / CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
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NAME: ` � ° 1
Last Name first Na t n Middle Initial
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HOME ADDRESS: t 9- 7 ® 6 - -�(2- SD IA L 3
Apk No. House No. /St t City State Zip Code
: 22— 7 3g - + 7b / -- � ,7 � PHONE. � ���1 X.3 �G
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Home I Work 4 4 1 Fa Email address
Business Name: eilii)/ D f / I 44 1 1 Position: G / e e--= r2__,
Address. / 72/ fr
No. treed City State - Zip Code
Professional License (describe) Expires: Attach a copy of the license
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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 fora minimum of six (6) months: Yes ❑ or No
• Demonstrate an ownership /interest in a business in N)iami Beach for a minimum of six (6) months: Yes ❑ or No O
• Are you a registered voter in Miami Beach: Yes ❑ or No
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
• Are you presently a registered lobbyist with the City o Miami Beach? Yes ❑ or No A0'
Please list your preferences in order of ranking [1] first clll oice [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
0 Art in Public Places Committee ❑ Miami Beach Commission for Women
0 Beautification Committee ❑ Miami Beach Cultural Arts Council
0 Board. of Adjustment* 0 Mimi Beach Human Rights Committee
❑ Budget Advisory Committee 2-Miami Beach Sister Cities Program
❑ Capital Improvements 'Projects Oversight Committee ❑ Normandy Shores Local .Government Neigh. Improvement
❑ Committee on the Homeless ❑ Parks and Recreation Facilities Board
❑ Committee for Quality Education in MB ❑ Personnel Board
❑ Community Development Advisory ( ❑ Planning Board*
❑ Community Relations Board ❑ Police Citizens Relations Committee
❑ Convention Center Adviso Board { ❑ Production Indust Council
❑ Debarment Committee ❑ Public Safety Advisory Committee
❑ Desk n Review Board* { ❑ Safet 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 Adviso Committee ❑ Waterfront Protection Committee
❑ Health Facilities Authority Board ❑ Youth Center Advisory Board cz,
,) ❑ 'panic Affairs Committee „
istoric Preservation Board C)
I L lousing Authority -t~ :, 1 ri
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❑ Loan Review Committee *Board Required to File State, Disclosure FalEtT1 g
Note: If applying for Youth Advisory Board, please indicate! your affiliation with the Scott Rakow Youth Center: cz, a fic"
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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❑ No 0. If yes, Y
lease list the names of your children, their
ages, annd which programs. List below:
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Child's name: Age: Program:
Child's name: Age: Program:
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,.��R .�A! tai= :�RfvlS��CARD AND C:�Iv1MlT�`FE��a�: Applicc�tic�n.�Joc ,F
• Have you ever been convicted of a felony: Yes ❑ or No If ye s, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes 0 o r No [14
- yes, yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ❑ or No des, explain i
Y y y p in detail
• Are you currently serving on any City Boards or Committees: Yes ❑ or Nod! If es; which board?
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• What orga in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties owned o ,ha ye an interest in, which are located within the Ci of Miami Beach:
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• I am now employed by the City of Miami Beach: Yes ❑ or NoChich department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent ❑, 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 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 ❑ Female
Ethnic 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 the Black racial rou s of Africa.
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42iisianic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, re regardless of r
p g 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 0 or NoD.
Employment Status: Employed V Retired ❑ HoMemaker ❑ Other 0
NOTE: If appointed, you will be required to follow certain laws which apply to city board /committee members.
These •
se laws include, but are not limited to, the following:
o Prohibition frorn 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.
`1 here. = est to the accuracy and truthf lness of a application and have received, read and will abide by Chapter 2,
Artie - of the City Code "Standards of onduct r City Officers, Employees and Agency Members."
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pp pr s Signature Date Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE: Applicatio . s‘wili remain on file for a.period of. one (1) calendar year.
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Received in the City Clerk's Office by : Date: / /2010 Control No 6 Date: /__/2010 " //
Name of Deputy ierk
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