Elsa Urquiza CITY OF MIAMI BEACH
BOARD AND COMMITTEE'APPLICATION FORM
NAME:
Last Na e � First Name ,� _/Middle 1�3
HOME ADDRESS: /
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Apt No. House No./Street City State Zip Code
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PHONE: �jof)53g� 6 r 30 / �o—0053
Home/ Work Fax Email address
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Business Name: Position:� � S
Address:
No. Street City State Zip Code
Professional License(describe) 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 affiliate,-rd witt-he cit ,'this
requirement.shall be fulfilled.in the following ways: a) an individual shall have been a .resident of the city for%a mum loAsix
months; or b) an individual shall:demonstrate ownershipCnterest for a minimum of six months in a business established ire city
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• Resident of Miami Beach for a minimum of.six(6) months:'Yes❑or No 0 z
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• Demonstrate an ownershiprnterest in a business in Miami Beach fora minimum of six(6) months: Yes❑or No ❑-7-
e Are you a registered voter in Miami Beach:Yes ❑or No ❑ `n
• (Please circle one): I am now.a resident of: North Beach South Beach Middle Beach
• 1 am applying for an appointment because I:have special abilities, knowledge and experience. Please list below: --�•,
•Are you presently.a registered lobbyist with the City of Miami Beach?'Yes 0 or No ❑
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).
❑Affordable Housing Advisory Committee O.Marine Authority
0 Art in Public Places Committee ❑Miami'.Beach Commission for Women
0 g2autification Committee 0 Miami Beach-Cultural Arts Council
oard of Adjustment ❑Miami'Beach Human Rights.Committee
❑Budget Adviso Committee 0 Miami=Beach Sister Cities.Program
❑Capital Im rovements'Pro'ects Oversight Committee 0 Normandy Shores Local Govemment.Neigh. Improvement
0 Committee on the Homeless '❑Parks and Recreation Facilities.Board
❑Committee for Quality Education in MB ❑Personnel Board
0 Community.Development Advisory ❑Planning Board*
❑Community Relations Board ❑Police Citizens Relations Committee
0 Convention Center Advisory Board ❑Production Industry Council
❑.Debarment Committee D'Safety Committee
0 Design Review Board'" ❑Single Family Residential Review Panel
❑Disability Access Committee 0 Sustainabili Committee
❑Fine Arts Board . 0 Transportation and Parking Committee
❑Gay, Lesbian, Bisexual and Trans ender .GLB ❑Visitor and Convention Authority
❑Golf Advisory Committee. ❑Youth Center Advisory Board.
0 Health Advisory Committee
❑Health Facilities Authority Board
❑Hispanic Affairs.Committee
0 Historic Preservation Board
0 Housing-Authori
0 Loan Review Committee *Board Required:to=File State;Disclosure Form
Note: If applying-for Youth Advisory Board,.-please indicate your affiliation with the Scot Rakow Youth Center:
1 Past service on-the Youth Center Advisory-Board: Yes 0 No❑ Years of Service:
2'. Present participation in Youth Center activities by your children Yeso No 0. 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:
F-.\CLER\$ALL\oF0UAS\BGARD AND COMMITTEES\BC Applicotion.dcc:
*Have you ever.been convicted of a felony- Yes ❑or No (9' If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes O or No 0' If yes, please'explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes❑ or No 0/1'f yes, explain in detail
• Are you currently servi g on any City arils r Co m 'ttees: Yes Nror No ❑. If yes; which board?
• What.organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all prope 'es owned or have an interest in, which are located within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes 0 or Noo. Which department?
o Pursuant-to City Code Section 2-25 (b): Do you have a parent 0, spouse❑, 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 equal opportunity reporting requirements.
Gender: 0 Male 0 Female
Ethnic Origin: Check one only (1)
❑White (Not of Hispanic Origin):All 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.
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Hispanic: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 tribal affiliation or community.recognition.
Physically Challenged: Yes 0 or No9l/
Employment Status: Employed 0 Retired 2/ Homemaker❑ Other❑
NOTE: If appointed, you7wili 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 hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Articl oft Ci ode "Standards of Conduct for City Officers, E RIo/yees and Agenc Members."
Applicant's Signature ate Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by Date:1 010 Control No Date: /_/2010
Narde of Deputy Clerk
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