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Merle Weiss LV MI AM I I3IAL H CITY OF MIAMI BEACH BOARD AN COMMITTEE APPLICATION FORM NAME: W e—t 5 5 P , r I E., Last Name �� y "1 First Dame Middle Initial HOME ADDRESS: ( ` I (oLt , 1 / . -- L l 3 r 3 7 C _ _ Apt No. + House N . /Street City t / �� State Zip Code PHONE: , 3 7,' 1I l� v GA n IR f" ,er t?I.P�L.ISS ( 1© G yf t ,�2 Home Work F x Email address Business Name Position Address CU - n No. treet City State Zip Code Professional License (describe) il lq, 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 minimum of six months in a business established in the city • Resident of Miami Beach for a minimum of six (6) mo hs. Yes ❑ or No ❑ • Demonstrate an ownership /interest in a business i iami 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 B -_ . - Middle Beach • I am applying for an appointment because I have special abilitie , ow edge and experience. Please list below • Are you presently a registered lobbyist with the City of Miami Beach? Yes ❑ or No ❑ Please list your preferences in order of ranking [1] first choice [2] second choice, and [31 third choice. Please note that only three (31 choices will be observed by the City Clerk's Office. (Regular Boards of City) ❑ Affordable Housing Advisory Committee 0 Marine Authority ❑ Art in Public Places Committee ❑ Miami Beach Commission for Women ❑ Beautification Committee ❑ Miami Beach Cultural Arts Council D Board of Adjustment* ❑ Miami Beach Human Rights Committee ❑ Budget Advisory Committee 0 Miami Beach Sister Cities Program L ❑ Capital Improvements Projects Oversight Committee 0 Normandy Shores Local Government Neigh. Improvement ❑ Committee on the Homeless ❑ Parks and Recreation Facilities Board ❑ Committee for Quality Education in MB 0 Personnel Board ❑ Community Development Advisory ❑ Planning Board* ❑ Community Relations Board ❑ Police Citizens Relations Committee ❑ Convention Center Advisory Board ❑ Production Industry Council (-- -, N- ❑ Debarment Committee ❑ Safe Committee .- , �, ❑ Design Review Board* ❑ Single Family ,residential Review Panel -< x '71 ❑ Disability Access Committee ❑ Sustamability Committee c?r ---) ❑ Fine Arts Board ❑ Transportation and Parking Committee - '"'rr = i < �. w € D Gay, Lesbian, Bisexual and Transgender (GLBT) ❑ Visitor and Convention Authority a t . m . f ❑ Golf Advisory Committee ❑ Youth Center Advisory Board r r ,- - o,_., -,- ❑Health Advisory Committee s, fet ❑ Health Facilities Authority Board ❑ Hispanic Affairs Committee cf, r — "o c D Historic Preservation Board c c + i .h "f_ ll ❑ Housing Authority - Ii -) ❑ Loan Review Committee *Board Required to File State DisclosurecfornU 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❑ to ❑ 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. I F \CLER \$ALL \o FORMS \3CARD AND COMMITTEES \BC Applicot on doc V •Have you ever been convicted of a felony Yes ❑ or No If yes, please explain in detail • Do you currently have a violation(s) of City of Miami Beach codes Yes 0 or No dyes, please explain In detail: • Do you currently owe the City of Miami Beach any money: Yes 0 or Nom I f yes, explain in detail • Are you currently serving on any City Boards or Committees Yes 19"or No,❑. If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name �tv\ 5 ) �t�f � – Title: SSG Fet r Name 1361 5 S rn 0 E' ) k` V\ Title: NYTh G. 'VV\ h (�'• • List all pr erties owned or have an in erest in, which are located within the City of Miami Beach. -c S (C3-�tl \ci e (/ 0 7 • I am now employed by the City of Miami Beach: Yes ❑ or No3Ahich 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) 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 e I opportunity reporting requirements. Gender: Male emale Et is Origin: Check one only (1) White (Not of Hispanic Origin). AU 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 tnbal affiliation community recognition. Physically Challenged: Yes 0 or N , / `r Employment Status. Employed ❑ Retired ❑ Homemaker/ Other ❑ S V 1_y ,e) 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. "I here attest to the accuracy truthfulness of the application and have received, read and will abide by Chapter 2, A ' e VI of the City Code "Standards of Co / u /J Ct for ity Officers, Employees and Agency Members. ", ? Signature .,,, - ar D / 7 / 6 / / Name ofA Merle W ASS Appli ant's f . �� �/ � Received in the City Clerk's Office by — �. / Date. L -�/ G'� control No/ 0 J Date /// /2010 1 4 / Name of Deputy Clerk