Samuel J. Reich Board Application . .
CA AA AAA BEACH CITY OF MIAMI BEACH
`.• BOARD AND COMMITTEE APPLICATION FORM
NAME: Re�(_� atmv42. 1 l
Last Name First Name y� Middle Initial
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HOME ADDRESS: ✓ t .. P «I r 1.e Awe ( �iq c,L Fl_ 331
Apt No. House No. /Street City State Zip Code
PHONE: 30 5 Sos oq 4 305 3 43 -9330 sa•--%Q baS� .lestio .Co„.,
� Home M Work Fax / Email address /
Business Name: 361 (7� ! r %Torcicle Ur 1 4 Position: QwL421 / Pre. il ..v1
Address: 1 7 P) C(- W el+ , 4v. 6 / - / 1 U+w; Qer) t Ft- 3 313 1
No. Street City S tate Zip Code
Professional License (describe) Expires: Attach a copy of the license
I 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: YesXor No ❑
• Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: YesXor No ❑
• 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 experien •-. - - . - • •elow: O■r4Qr OS' .4
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ❑ or No tua OA c. t e n laa h
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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 ❑ Housing Authority
❑ Art in Public Places Committee ❑ Loan Review Committee
❑ Beautification Committee ❑ Marine Authority
❑ Board of Adjustment* ❑ Miami. Beach Commission for Women
❑ Budget Advisory Committee ❑ Miami Beach Cultural Arts Council
❑ Capital Improvements Projects Oversight Committee ❑ Miami Beach Sister Cities Program
❑ Committee on the Homeless ❑ Normandy Shores Local Government Neigh - Jmpglement
❑ Committee for Quality Education in MB ❑ Parks and Recreation Facilities Board 2 �
❑ Community Development Advisory ❑ Personnel Board -'„' ;tJ
❑ Community Relations Board ❑ Planning Board* rC- O 'T)
❑ Convention Center Advisory Board ❑ Police Citizens Relations Committee r- r1 _ ;7
❑ Debarment Committee ❑ Production Industry Council ' c11 rn
❑ Design Review Board* ❑ Public Safety Advisory Committee �:
❑ Disability Access Committee ❑ Safety Committee 3
❑ Fine Arts Board ❑ Single Family Residential Review Panel o r 1
❑ Gay, Lesbian, Bisexual and Transgender (GLBT) • Sustainability Committee ,--1 4. L
Committee ' (")
❑ Golf Advisory ��, Transportation and Parking Committee r� (
'° ■ Health Advisory Committee —` ❑ Visitor and Convention Authority
t ■ Health Facilities Authority Board ❑ Waterfront Protection Committee
❑ Hispanic Affairs Committee ❑ Youth Center Advisory Board
❑ Historic Preservation Board
*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 ❑ Years of Service:
2. Present participation in Youth Center activities by your children Yes❑ 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:
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•Have you ever been convicted of a felony: Yes or NoX If yes, please explain in detail: `
• Do you currently have a violation(s) of City of Miami Beach codes: Yes or No C. If yes, please explain in detail:
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• Do you currently owe the City of Miami Beach any money: Yes or NoX If yes, explain in detail W e 'r,,..reV
c_ ,P e r e ,n'A y -
• Are you currently serving on any City Boards or Committees: Yes or NoY If yes; which board? 55' f
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• What organizations in the City of Miami Beach do you currently hold membership in? -
t Name: Title:
Name: Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
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• I am now employed by the City of Miami Beach: Yes 7 or No( Which department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent I, spouse ❑, child D, brother -, 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.
w 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 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 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 direct) or indirectly lobbying city y y y g y 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.
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"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII — of tJ4 City o,de "Standards of Conduct for City Officers, Employees and Agency Members."
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x Applica s Signature Date ) Name of Applicant (PLEASE PRINT)
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f Received in the City Clerk's Office by : ` Date: _/ /2010 Control No. Date: / /2t31 ( /
Name of Deputy Clerk F: \CLER \$ALL \aFORMS \BOARD AND COMMITTEES\ pplica on.doc
CA MIAMIBEACH RECEIVED
City of Miami Beach, 2010 NOV 15 PM 4: 34
1700 Convention Center Drive,
Miami Beach, Florida 33139, CITY CLERK'S OFFICE
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)
Board Member name: u`M"� 0 ° ''z'J'\
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, 2010.
1. A "Source of Income Statement (attached) or
2. A "Financial Statement (attached( orj
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: