Patricia G. FullerCITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
FullerPatrciaG
NAME:
First Name
Last NameMiddle Initial
1577Bay R33139
HOME ADDRESS
:
2051577Bay RMiami Beach
Home No./StreetState
Apt No.City
Zip Code
pgfuller@earthlink.net
617.759.5657
PHONE
:
WorkEmail Address
HomeFax
Business Name:
Position:
Miami BeachFL
Address:
State
No.
CityZip Code
Street
Expries:
Attach a copy the license
Professsional License (describe):
Pursuant to City Code section 2-22(4)a and b:
Members of agencies, boards, and committees shall be affiliated
requirement shall be fulfilled in the following ways:a)an individual shall have been a resident of the city for a minim
months; or b)an individual shall demonstrate ownership/interest for a minimum of six months in a business established i.
● Yes
Resident of Miami Beach for a minimum of six (6)months:
● No
Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6)months:
●
Are you a registered voter in Miami Beach:
Yes
● South Beach
(Pleasecircle one):I am now a resident of:
●
I am applying for an appointment because I have special abilitie.Please list below:
please see resume
●
Are you presently a registered lobbyist with the City of Miami B
No
123Please note that only three (3)
Please list your preferences in order of ranking []first choice []second choice, and []third choice.
choices will be observed by the City Clerks Office.
(Regular Boards of City)
Affordable Housing Advisory CommitteeHousing Authority
[1]Art in Public Places CommitteeLoan Review Committee
Beautification CommitteeMarine Authority
Board of Adjustment*Miami Beach Commission for Women
Budget Advisory CommitteeMiami Beach Cultural Arts Council
Capital Improvements Projects Oversight CommitteeMiami Beach Human Rights Committee
Committee for Quality Education in MBMiami Beach Sister Cities Program
Committee on the HomelessNormandy Shores Local Govt Neigh.Improvement
Community Development AdvisoryParks and Recreation Facilities Board
Community Relations BoardPersonnel Board
Convention Center Advisory BoardPlanning Board*
Debarment CommitteePolice Citizens Relations Committee
Design Review Board*Production Industry Council
Disability Access CommitteeSafety Committee
Fine Arts BoardSingle Family Residential Review Panel
Gay, Lesbian, Bisexual and Transgender (GLBT)Sustainability Committee
Golf Advisory CommitteeTransportation and Parking Committee
Health Advisory CommitteeVisitor and Convention Authority
Health Facilities Authority BoardWaterfront Protection Committee
Hispanic Affairs CommitteeYouth Center Advisory Board
Historic Preservation Board
Note
:If applying for Youth Advisory Board, please indicate your affil:
1.Past service on the Youth Center Advisory Board:
No
Years of Service:
if yes, please list the names of your children, their
No
2.Present participation in Youth Center activities by your childre
ages, and which programs.List below:
Age:Program:
Child's name:
Age:Program:
Child's name:
● No
Have you ever been convicted of a felony:If yes, please explain in detail:
●
Do you currently have a violation(s)of City of Miami Beach codes:
No
If yes, please explain in detail:
● No
Do you currently owe the City of Money Beach any money:If yes, please explain in detail:
● No
Are you currently serving on any City Boards or Committees:If yes, which board?
●
What organizations in the City of Miami Beach do you currently h
SoBe Bay Condo AssociationPresident
Name:Title:
Name:Title:
●
List all properties owned or have an interest in, which are loca:
● No
I am now employed by the city of Miami Beach:Which department?
● Pursuant to City code Section 2-25(b):
do you have a relative 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 yo. It is
being asked to comply with federal equal opportunity reporting r.
Gender:Male
Ethnic Orgin:Check one only (1)
White
No
Physically Challenged:
Homemaker
Employment Status:
NOTEIf appointed, you will be required to follow certain laws which /committee members.
:
These laws include, but are not limited to, the following:
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 leavin(Miami
o
Beach Code section 2-26).
Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
o
(re:CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving offi
from having any interest in or receiving any benefit from Co
or those with whom you have business or immediate family ties (CFR570.611).
Upon request, copies of these laws may be obtained from the .
I hereby attest to the accuracy and truthfulness of the applicat2, Article
VIIof the City Code Standards of Conduct for City Officers, Employees and Agency Mem.
I Patrcia Fuller agreed to the following terms on 12/20/2011 10:08:01 AM
Received in the City Clerk's Office by:Date: / /2011Control No.Date: / /2011
Name of Deputy Clerk