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William H. Warren, Jr.CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM Warren, Jr.WilliamH NAME: First Name Last NameMiddle Initial FL33139 HOME ADDRESS : 202810 11th StreetMiami Beach Home No./StreetState Apt No.City Zip Code bwarren@bdrinsurances.com 305-495-3472305-604-8035305-604-8045 PHONE : WorkEmail Address HomeFax President Business Name: Benefits Design Resources, Inc. Position: 407Lincoln RoadMiami BeachFL33139 11-H Address: State No. CityZip Code Street Florida Insurance LicenseApril2013 Expires: 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: ● Yes 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: A resident of Miami Beach since 1994, have done work with 2equlity organizations in Miami-D ● 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 Clerk’s Office. (Regular Boards of City) Affordable Housing Advisory CommitteeHousing Authority 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 Committee[1]Miami Beach Human Rights Committee Committee for Quality Education in MBMiami Beach Sister Cities Program Committee on the HomelessNormandy Shores Local Gov’t 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 Miami Beach Chamber of CommerceMember Name:Title: Miami-Dade Gay and Lesbian Chamber Member Name:Title: of Commerce ● List all properties owned or have an interest in, which are loca: 810 11th Street, Apt. 202 ● 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) African-American/Black No Physically Challenged: Employed Employment Status: NOTE: If 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 VII–of the City Code “Standards of Conduct for City Officers, Employees and Agency Mem.” I William Warren, Jr.agreed to the following terms on 1/16/2012 5:54:07 PM Received in the City Clerk's Office by:Date: / /2012Control No.Date: / /2012 Name of Deputy Clerk