Melvin Brazer Board & Committee @ City of Miami Beach 10/13/11 4:13 PM
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BOARD AND COMMITTEE :.
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APPLICATION FORM �►
/'1 L v t N Name
First Name
Middle Initial j t a 2—C• e
Last Name ..__..__._
1406 Home Address
Apt No s 4 A N V La.t L
House # \Street
City Miami Beach
State Florida r :'•
Zip Code 33 % _. '3
Contact Information
Home /Cell 7 ?4. 33
Work
Fax
E -mail Address PL ( gfl 2 c R G r+'1 A <<' Cow
Business Information
Business Name
Position
Business Address
Apt No.
House # \Street
City Miami Beach
State Florida
Zip Code
Professional License (describe) Expires: : ' ' '
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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 for a minimum of six (6) months: )(Yes No
Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes YNo
Are you a registered voter in Miami Beach: )4Yes..;No
(Please circle one): I am now a resident of: °North Beach South Beach ';Middle Beach
Are you a politically or registered lobbyist with the City of Miami
Beach Yes N
I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
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)
Click here to view all available Boards and Committees.
Affordable Housing Advisory Committee 1, Loan Review Committee
Art Public Places Committee Marine Authority
.. •.j Beautification Committee :: Miami Beach Commission for Women
',LIP Board of Adjustment Miami Beach Cultural Arts Council
http: // secure. miamibeachfl. gov/ bcapp/ bcapplication .aspx ?Application,D= 2882 , �' Page 1 of 3
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Board & Committee @ City of Miami Beach 10/13/11 4:13 PM
: 1 Budget Advisory Committee 1 Miami Beach Human Rights Committee
Capital Improvements Oversight Miami Beach Sister Cities Program
1 Committee on Homeless _ Normandy Shores Local Gov't Neigh. Improvement
. ?' Committee for Quality Education in MB 1 Parks and Recreation Facilities Board
Community Development Advisory 1 I Personnel Board
1. Community Relations Board a Planning Board
1 Convention Center Advisory Board 1' Police Citizens Relations Committee
' Debarment Committee a_ Production Industry Council
•
Design Review Board* Public Safety Advisory Committee
Disability Access Committee :' Safety Committee
Fine Arts Board 12 Single Family Residential Review Panel
' : ;' Gay, Lesbian, Bisexual and Transgender (GLBT) : ;; Sustainability Committee
1 Golf Advisory Committee 1 Transportation and Parking Committee
Health Advisory Committee _ ,,,,,, 1 . „ Visitor and Convention Authority
f . 1 Health Facilities Authority Board Waterfront Protection Committee
: Hispanic Affairs Committee . Youth Center Advisory Board
1 ` Historic Preservation Board RTS C d "NCI Z--:
� li LT4 T21�
. 1, Housing Authority
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:
z
L
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: I
Child's name: Age: Program:
Child's name: Age: Program:
Have you ever been convicted of a felony: If yes, please explain in detail:
Yes No
Do you currently have a violation(s) of City of Miami Beach codes: }Yes 7CNo If yes, please explain in detail:
Do you currently owe the City of Miami Beach any money: °Yeso If yes, explain in detail
Are you currently serving on any City Boards or Committees: C Yes yNo If yes, explain in detail
What organizations in the City of Miami Beach do you currently hold membership in?
Name : G try 40 i / //
............__�...� ..___ �_.. �. �._.... �. .V..._.._..�.._,.�.._._____.... �_...
, ASK t (3c1.4c 6 Ti tl e
Name: Lc. n A 1i R s h y ,
C A aD t Title:
List all properties owned or have an interest in, which are located within the City of Miami Beach:
/5l—k.. D J E e
I am now employed by the City of Miami Beach: °Yes '$No Which department?
Pursuant to City Code Section 2- 25(b): Do you have a
Parent Spouse Child Brother Sister
who is employed bythe City of Miami Beach? Check all that apply.
Identify the department(s):
Gender: XMale Female Race: White - Black
Ethnic Origin (Check one)
-hate African- American /Black Hispanic Asian or Pacific Islander American Indian or Alaskan Native
Y g
Ph sicall Challenged:
Y
Yes No
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Board & Committee @ City of Miami Beach 10/13/11 4:13 PM
Employment Status: KRetired
;.Employed :: Home -maker ;W; 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 laws may be obtained from the City Clerk.
NOTE: Applications will remain on file for a period of one(1) calendar year.
"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."
The City Clerk's Office reserves the right to contact you for verification purposes.
Agree
Submit Form
http: // secure. miamibeachfl. gov /bcapp /bcapplication .aspx ?ApplicationID =2882 Page 3 of 3