Orlinda Perez Perez Board Application r
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C __AMIAMI BEACH CITY OF MIAMI BEACH
BOARDS AND COMMITTEE APPLICATION FORM
NAVE.: PeitO ? Ros e cv(h da.
Last Name Hirst Name didrle Mal
H ONE ADORES& y54 NLU ,- ue /'u mi • FL 35/25
Nor. Skeet City Stale Zip Code
PHONE: B 3 lq - oo 1 3
Work Fau Bred address
Business Nanny~ /U/ f Podium
Address:
No. Street aty Sale Bp Code
Pr onal License desrnbe) Expires Attach a copy of the license
5' e /Po tv,-2K I:5 0/c1 C /r/ pp.-
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and com.riimees shall be affiliated with the dty; this
requirement shall be fulfilled in the hollowing ways: a) an individual shall have been a resident of the dty for a mnirwnun of sic
months; or b) an individual strati demonstrate ownershiplidenast for a nrremrm of six mouths in a business estabished in the city.
• Resident of Miami Beath for a minimum mn of six (6) monk Yes fitior No K
• Demonstrate an ownershipfirderest in a business n Miami Beach for a minimum of six (6) months: Yes ED or No X
• Are you a regishsed voter in Ilibarni Beach: Yes Xpr No C
• (Please check one): 1 am now a resident of: North Beach Di South Beach E Y"iddle Bear E N/i9
• 1 am applying for an appointment because 1 have special ate, knowledge, experience. Please ist below
Please ist your pry in order of ranking 111 fist choice 121 second deice, and I3] Mid choice. Please note that odv three (3)
droioes wN be observed by tJre CiEur t3erit's tlWoa . (Regular Boards oft y)
o Art in Pubic Places Committee o Housing Authority*
o Beach Privation Board 0 Loan Review CouTitlee*
o Beautification Committee 0 Maya's Green Ad-Hoc Camritee
o Board of A44ustmenr 0 Marine Authority*
o Budget Advisory Camunllee ® Mani Beady Cultural Arts Council
o Committee on Homeless 0 Miami Beach Commission an Status of Women
o Committee for Quaky Education in MB 0 Miami Beach Florida Sister Cites
o Community Developmernt Advisory* 0 Normandy Shores Local Gov't Neigh Improvement
❑ Community Relations Board 0 Oversight Cormitee for General ObigaionAprid
o Convention Center Advisory Board 0 Parks and Recreation Facilities Board =I'
o Debarment Canenttee 0 Personnel Board" ..‹ `'1 _ - .
o Design Review Board* 0 Planning Board' C) rrt rm
o Disabdity Access Conerritee 0 Rice Citizens Relations Committee r _ C")
o Fme Arts Board 0 Production industry Coast o 11
o Golf Advisory Committee ID Pubic Safety Advisory Connilee 1
CA Is AC'
o Health Advisory Committee i( Safety Committee ee _
o Health Fadities Authority Board "Transportation and Paring Committee 'n O m
o Hispanic Affair Committee 0 Visitor and Convention Authority* -n t+ ►t Z7
o Historic Preservation Board` o Youth Center Advisory Board rr Cn
* Board Required to Fite State Disclosure Tons
1
C:1Docurpents and Settirlgs Settings\Temporary Internet Files\OLK1C51BC Application Revised July 18 2007.doc
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Note: If applying for Youth Advisory Board, please indicate your allirdion wilh 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 dddren YesD No 9 4 If yes, please list the names of your dildnan, their
ages, and which programs. List below:
Child's name: e Program:
Child's name: Program:
.Have you ever been convicted of a felony: Yes D or No% If yes, please explain in dead:
• Do you currently have a violation(s) of City of Ream' Beach codes: Yes 0 or NofrA If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes 0 or No% If yes, explain in detal
• Are you currently serving on any City Boards or Committees: Yes 0 or No If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in? 11./114
Name:
Name:
• List all properties owned or have an interest in, which are located within the aly of Miami Beach: /VP
• I am now employed by the City of Miami Beach: Yes 0 or Nsi<Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent 0, spouse 0, child 0, brother 0 or sier0 who is employed by the
City of Miami Beach? Check al that apply. Identify the department(s):
This section is not required" but desired: Age: 6 6 years old Gender: Male it Female Ethnic Origin (Check one)
White 0 African-American/Mad( IIspaniix 0 Asian or Pacific Islander 13 American Inchon or Alaskan Native 0
Employment Status: Employed 0 Retired 0 Home-maker 0 Other 0
1 hereby attest to the accuracy and buthfulness of the appication and have received, read and sal abide by Chapter 2,
Article VII — of the Catty Code "Standards of Conduct for City Officers, Employees and Agency Members."
(974 t9d (9,//rida_ Piege
Appicard's Signature Name of Applicant (PLEASE PRINT)
Phase attach a copy of your resume to this application
NOTE: Applications will remain on tie for a period of one (1) calendar year.
Received in City Oates Office by Dale
Name at Deputy Clerk
Document Control Number (Assigned by the City Cedes O�) 5 Edens! Ely...412L D reg21 §:ti
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