Luz A. Rojas _ M I AM I B EAC H CITY OF MIAMI BEACH
BOARD A14D COMMITTEE APPLICATION FORM
NAME: Ll hJ
Last Name 1 pp l First Name /� TMiiddle Initial
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Apt rNo. House No./S eet City State Zip Code
PHONE: 3O� libr � O7 l F6-3Pii0 7 2 r,D ps 7 a; •C:��"
Home T _ Work Fax - �Emai address
Business Name: �� 1 Jbl(1 f'�L�(S �JG. Position: �W L ) �' jC_�_Cp
Address:
No. Street City State Zip Code
Professional License(describe) Expires: Attach a coPe 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)months:Yes�Kbr No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months: Yes D or No ❑
•Are you a registered voter in Miami Beach: Yes 0 or No ❑
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I 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 D or No 0
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)
0 Affordable Housing Advisory Committee ❑Historic Preservation Board
0 Art in Public Places Committee 0 Housing Authority
❑ Beautification Committee ❑ Loan Review Committee
❑ Board of Adjustment* 0 Marine Authority
D Budget Advisory Committee 0 Miami Beach Commission for Women
0 Capital Improvements Projects Oversight Committee 0 Miami Beach Cultural Arts Council
0 Committee on the Homeless 0 Miami Beach Human Rights Committee
❑ Committee for Quality Education in MB 0 Miami Beach Sister Cities Program
0 Community Development Advisory 0 Normand Shores Local Government Neigh. Improvement
❑Community Relations Board ❑ Parks and Recreation Facilities Board
❑Convention Center Advisory Board 0 Personnel Board
0 Debarment Committee ❑ Planning Board*
❑Design Review Board' ❑Police Citizens Relations Committee
0 Disability Access Committee 0 Production Industry Council
0 Fine Arts Board 0 Safety Committee
❑Gay, Lesbian, Bisexual and Trans ender(GLB 0 Single Famil Residential Review Panel
0 Golf Advisory Committee D Sustainabilit Committee
❑Health Advisory Committee ❑Transportation and Parking Committee
❑ Health Facilities Authority Board ❑Visitor and Convention Authority
His anic Affairs Committee ❑Waterfront Protection Committee
0 Youth Center Advisory Board
*Board Reg uired to File State Disclosure Form
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 0 Years of Service:
2. Present participation in Youth Center activities by your children Yes❑ No 0. If yes, please list the names.of your children, their
ages, and which programs. List below:
Child's name: Age: Program: IjI 4 gn .1d?I 11 Ia
Child's name: Age: Program:
FACLER\$ALL\oFORMS\BOARD AND COMMITTEES\BC Application.doc
UJA130 ��
.Have you ever been convicted of a felony: Yes ❑or NO'A yes, please explain in detail:
e'Do you currently have a violation(s)of City of Miami Beach codes: Yes 0 or No,\/lf yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes 0 or No)<If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes❑or NOX If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties 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 ❑or Noxwhich department?
e Pursuant to City Code Section 2-25(b): Do you have a parent 0, spouse D,child 0, brother❑, 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: ❑ Male 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.
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 D or No \\
Employment Status: Employed❑ Retired❑ Homemaker❑ Other ::'F i LN ti AK��L.(i Foci C.E 1
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.
"Werebyltt st to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
A h City Code"Standards of Conduct for City Officers,Employees and Agency Members."
Ap Ual Lanri gn re Date Name of Applicant(PLEA!8E PRINT)
Date: _/2010
Received in the City Clerk's Office by: Date:_/ 12010 Control No. _/
Name of Deputy Clerk