David S. Wieder ' From David Wieder Fax:+1(305)866-7621 '2 To City of Miami Beach CIE Fax: +1 (305)673-7254 Page 1 of 2 12/27/2011 6:05
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I AM G tv\ i BEACH CITY OF MIAMI BEACH FORM
BOARDS AND COMMITTEE APPLICATION FORM
NAME: I. � DP*00 o
!Laast Name First
n /� AFirst Name �, Middle Initial
HOME ADDRESS: !/ ' 4 V ?-70--ti 0._ ,iI //1M 1 ?31,'/t , t' 'J �/v/
7rn No. / Street t' I '70/7.?City ,/ - Statee Zip Code
PHONE: 7v j �g� r �('d �C ei t'vrlr'' E�l�t C`�f 0J//a./ve'f"'
Home if Work Fax 47-7-101/P--/Em�aiil address
Business Name: D"4,41) 5, r J2 //f Position:
Address. "/ '` 7/ S'T J 1.'r Y r) 44 1,4141 1Cif FL -431` /
41 No. Street
`' /j Street 2/j� City /1.1/4---State Zip Code
Professional License(de�spribe) 1 O/C I Jiff. � �Y J`' Expires: Attach a copy of the license
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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,orb)art 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 ❑
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• Demonstrate a6 ownership/interest in a business in Miami Beach for a minimum of six(6)months Yes or No ❑
•Are you a registered voter in Miami Beach.Yesor No 0
' • (Please check o'ne): I am now a resident of North Beach)South Beach 0 Middle Beach 0
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• I am applying for.an appointment because I have special abilities, knowledge, experience Please list below*
A- ; 11--,�Lye/ye'i a. AEA/Oi"T/4 i'T6 Hfl,? .
Please list your preferences in order of ranking[1]first choice[2)second choice, and[3]third choice. Please note that only three (31
choices will be observed by the City-Clerk's Office.(Regular Boards of City)
0 Art irr Public Places Committee 0 Housing Authority*
❑Beacj'Preservation Board ❑Loan Review Committee'
0 Beaufifrcation Committee 0 Mayor's Green Ad-Hoc Committee
0 Board of Adjustment* 0 Marine Authority'
0 Budget Advisory Committee ❑Miami Beach Cultural Arts Council
0 Committee on Homeless 0 Miami Beach Commission on Status of Women
o Committee for Quality Education in MB 0 Miami Beach Florida Sister Cities
0 Community Development Advisory` 0 Normandy Shores Local Gov't Neigh. Improvement
0 Community Relations Board 0 Oversight Committee for General Obligation Bond
0 Convention Center Advisory Board ❑Parks and Recreation Facilities Board
0 Debairient Committee 0 Personnel Board'
0 Design Review Board" ❑Planning Board'
' ❑Disability Access Committee ❑Police Citizens Relations Committee
0 Fine Arts Board 0 Production Industry Council
0 Golf Advisory Committee 0 Public Safety Advisory Committee
0 Health Advisory Committee 0 Safety Committee
0 Healffi.Facilities Authority Board 0 Transportation and Parking Committee
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0 lspa i¢Affairs Committee ❑Visitor and Convention Authority`
Historic
:Preservation Board' 0 Youth Center Advisory Board
'Board Require FI'Ie State Disclosure form
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C:\Docurnents and Setliri slcompurbrnlLocal SettinuslTomporevry Inte:met Filesl;)LI`1C5'BC Application Revisal July IC 200; dre
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From David VUeder Fax +1(305),(366-7621 '2 To City of Miami Beach CIE Fax +1 (305)673-7254 Page 2 of 2 12/27/2011 6 05
Note.If applying for:Youth Advisory Board,please indicate your affiliation with the Scott Rakow Youth Centei
1 Past service on the Youth Center Advisory Board Yes Li No Li Years of Service:
2 Present participaitipn in Youth Center activities by your children Yes:1 No n If yes, please list the names of youi 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 0 or Nolf yes,please explain in detail:
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• Do you currently have a violation(s)of City of Miami Beach codes- Yes 0 or No If yes, please explain in detail
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• Do you currently,Owe the City of Miami Beach any money:Yes rl or Not If yes, explain in detail
•Are you currently,'serving on ny Cit Boards or Committees:Yes, l or No D. If yes,which board?
WI 5 / P i(- CKLIA-ri N4 .
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• What organizations in the City of Miami Beach do you currently hold membership in?
Name' ri Title
t.o V
Name ■
Title'1i;i _
• List all properties-owned or have an interest in,which are located wit the City of farm Beach
Iwo tifiple Rai r;► 101 ,01,, 1 ,
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• I am now employed by the City of Miami Beach:Yes 0 or No (Which department?
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• Pursuant to City C(bde Section 2-25(b):Do you have a parent 0,spouse 0,child LI,brother 0,or sister n who is employed by the
' City of Miami Beach.rheck all that apply Identify the department(s).
This section is"not squired"but desired.Age: 6/ years old Gender Mal,_ Female 0
Ethni Agin(Check one)
White African-Arrincan/Black 0 Hispanic 0 Asian or Pacific Islander 0 American Indian or Alaskan Native 0
Employ ent StatuCEmptoyed 0 Retired 0 Home-maker 0 Other 0
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"I her:r attest to'th- : cure y and truthfulness of the application and have received, read and will abide by Chapter 2,
A of that' ode .ndards of Conduct for City Officers,Employees and Agency Members."
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/L i 0 1 't--- l dill 7)ftJIO ; 1A/4-W&4._
App icant's Sig,-'lure Date Name of Applicant(PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE:Applications'will remain on file for a period of one(1)calendar year.
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Received in City Clerk's'; fAce by Dale
`I: Name of Deputy Clerk
Document Control Numbi r(Assigned by the City Clerk'p Office) Entered By- Dale
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R arse 125!0710
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C\Documents and Selby slcomourbm\Local Setimgs'Tenlpoiary Intl met Files1OLK 1C5U3C Application Riaviced July IL[uW d:,
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