Steven M. Gonzalez ED x/11 1 Bij,CH
CITY OF MIAMI BEACH
BO AN COMMITTEE APPLICATION FORM
NAME: b il. -� (L.I.-- I
Last N ame first Name M' dle Initial
HOME ADDRESS: 3 7 J 0 C 0 �� �\r■
Apt No. House � Noo. /Street City Stat , Zip Code
PHONE: 3os c' S c� 1 Nv f\ --�- iez G sC_hn 0 if. „e)
Home Work Fax Email address
Business Name: Position:
Address:
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; 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 ' imum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: Yes or No ❑
• Demonstrate an ownership /interest in a business in aami Beach for a minimum of six (6) months: Yes ❑ or 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 experi nce. - - - - ' . - .• :
• Are you presently a registered lobbyist with the City of Miami Beach? Yes 0 or 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)
_0 Affordable Housing Advisory Committee 0 Marine Authority
❑ A Public Places Committee ❑ Miami Beach Commission for Women
eautification Committee al 0 Miami Beach Cultural Arts Council
❑ Board of Adjustment* ❑,Miami Beach Human Rights Committee
❑ Budget Advisory Committee 0 Miami Beach Sister Cities Program
0 Capital Improvements Projects Oversight Committee _ ❑ Normandy Shores Local Government Neigh. Improvement
0 Committee on the Homeless 0 Parks and Recreation Facilities Board
❑ Committee for Quality Education in B ❑ Personnel Board
M Community Development Advisory C,,uLf ra,■44 ra ,N') ❑ Phnning Board*
0 Community Relations Board Q'Police Citizens Relations Committee CL3
❑ Convention Center Advisory Board P�r uction Industry Council
0 Debarment Committee
5 fi lic Safety Advisory Committee
❑ Design Review Board* ®'Safety Committee
❑ Disability Access Committee ❑ Single Family Residential Review Panel
0 Fine Arts Board ❑ Sustainability Committee
0 Gay, Lesbian, Bisexual and Transgender (GLBT) ❑ T3Rfportation and Parking Committee
0 Golf Advisory Committee 2/isitor and Convention Authority v2
0 Health Advisory Committee
0 Waterfront Protection Committee
❑ Health Facilities Authority Board ❑ Youth Center Advisory Board
❑ Hispanic Affairs Committee
0 Historic Preservation Board
0 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: Yes 0 No 0 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:
F: \CLER \$ALL \aFORMS \BOARD AND COMMITTEES \BC Application.doc
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•Have you ever been convicted of a .y. Yes ❑ or No If yes, please explain :ail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or No . If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ❑ or No . If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes
iii
or No Q. If yes; which board?
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• 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:
• I am now employed by the City of Miami Beach: Yes ❑ or No hich department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister 0 who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
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The following informati • voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to com with federal equal opportunity reporting requirements.
Gender: ale ❑ Female
Ethnic Origin: Check one only (1)
❑ White of of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
❑ can - 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 Somas.
❑ 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 co munity recognition.
Physically Challenged: Yes 0 or No0
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 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 taws may be obtained from the City Clerk.
"1 hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
- i jig !At Iide "Standards of Conduct for City Officers, E yees and Agency Members." 5 i 1 1 (
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Ap. - i r= Date Name of Applicant (PLEASE PRINT) O N 6,
)1 . - '' . ...- ,
Received in the City Clerks Office by : k ,,, Date: / /2010 Control N (" 5 Date: 7 , / z : . 7 /204
Name of Deputy Clerk