Daniel N. Sherbill MIAMIBEACH CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
NAME: �ll�i��l G•L U,4AA14t97L A/
Last Name First Name ,/� Middle Initial
HOME ADDRESS: erge /6 23 GL/NS' 4e=l /`�/�/�'AZ 3 2z:!j
Apt No. House No.lStreet City State Zip.Code
PHONEAg �Z16-7.270 Email address .
Home _ Work Fax
Business Name: —rAVWPlk Position: �2A4676i
Address:-_ 1701 W A QV1Ae.,v7jXj 4ZIA1,X�e- 4114&1.AAe�W
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 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 ownershipAnterest 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 0
•Demonstrate an ownershiprinterest in a business in Miami Beach for a minimum of six(6)months:Yes❑or NOX
•Are you a registered voter in Miami Beach:Yes 0 or NoA
•(Please circle one):I am now a resident of. North Eleach South Beac -- Middle Beach
• !am applying for an appointment because I have special abilities, knowled a and experience.e. Please list below:
er.00 JSE G GK'�EG1G i0l-S 4Z 4A OF. W;ZO�bG/�G
•Are you presently a registered lobbyist with the City of Miami Beach?Yes 0 or No
Please list your preferences in order of ranking 111 first choice[2]second choice,and [31 third choice. P_lease note that only three(3)
choices will be observed by the Clty Clerk's Office.(Regular Boards of City)
0 Affordable Housing Advisory Committee ❑Historic Preservation Board
❑Art in Public Places Committee 0 Housing Authority
Z JB Beautification Committee ❑Loan Review Commfte
❑Board of Adjustment* 0 Marine Authority
❑Budget Advisory Committee 0 Miami Beach Commission for Women -�°
❑Capital Improvements Projects Oversight Committee 0 Miami Beach Cultural Arts Council
ll Committee on the Homeless 0 Miami Beach Human Rights Committee`'
❑Committee for Quality Education in MB 3 X Miami Beach Sister Cities Program ;
❑Community Development Advisory ❑Normandy Shores Local Government Net h.i mve-ent
❑Community Relations Board ❑Parks and Recreation Facilities Board
❑Convention Center Adviso Board ❑Personnel Board
❑Debarment Committee ❑Planning Board*
❑Design Review Board* ❑Police Citizens Relations Committee
0 Disabirdy Amen,committee ❑Producfion Indu Council
0 Fine.Arts Board ❑Safety Committee
❑Gay,Lesbian.Bisexual and Trans ender(GLB ❑Single Family Residential Review Panel
0 Goff Advisory Committee ❑Sustainability Committee
❑Health Advisory Committee 0 Transportation and Parldng Committee
❑Health Facilities Authority Board 0 Visitor and Convention Authority
0 Hisoanic Affairs Committee ❑Waterfront Protection Committee
❑Youth Center Advisory Board
*Board Required 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+O No 0. If yes, please list the names of your children,their
ages,and which programs.List below:
Child's name: Aee: "1 I;�Rlfaggl:!' `fit i i
Child's name: Age: m:
FACU-:R\$ALL\aFORMS\BOARD AND COMMITTEES\BC Appficafion.doc
i ,
*Have you ever been convicted of a felony: Yes❑or No)4 If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes❑or No X If 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 0 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:
1i lA
• I am now employed by the City of Miami Beach:Yes 0 or No)(Which department?
• Pursuant to City Code Section 2-26(b): Do you have a parent 0,spouse 0,child 0,brother 0, or sister 0 who is employed by the
City of Miami Beach?Check all that apply.Identify the department(s): XJIA
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.
Gander. `6 Male 0 Female
Ethnic Origin: Check one only(1)
'4 White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East.
❑African-AmericaNBlack (Not of Hispanic Origin):All persons having origins In any of the Buck racial groups of Africa.
❑Hispanic: All persons of Me)acan,Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin,regardless of race.
❑Asian or Pacific Islander:Ail 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 glands and Somoa.
❑American Indian or Alaskan Native: Ail persons having origins in any of the original peoples of North America,and who maintain
Cultural identification through tribal affifiation or community recognition. '
Physically Challenged: Yes 0 or NoO.
Employment Status: EmployeA Retired 0 Homemaker 0 Other l7
NOTE: If appointed,you will be required to follow certain laws which apply to city boardicommittee members.
These laws include,but are not limited to,the following:
• Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-458).
• Prohibition from contracting with the city(Miami-Dade County Code section 2-11.1).
• 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).
• 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.
a test to the a uracy and truthfulness of the application and have received, read and will abide by Chapter 2,
of e e"Standards of Conduct for City Officers,Employees and Agency Members."
8/�o/zoi M.411 L N ignature Date' Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by: Date:—/ 12010 Control No. Date: I !2010
Name of Deputy Clerk
i
AM MIAMI BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach,Florida 33139,
www.miarnibeachfl.aov
CITY CLERK Office CKlark@miamibeochfl.gov
Tel:305.673.7411 , Fax:305.673.7254
Acknowledgement of fineslsuspension for Board Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(1) (2)
Board Member name:
I understand that no later than July 1, of each year all members of Boards and Committees of the City of
Miami Beach, including those of a purely advisory nature, are required to comply with Miami-Dade County
Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary
responsibility is to recommend legislation or give advice to the City Commission, must file, even though you
may have been recently appointed.
You must file One of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida, by July 1 each year.
1. A"Source of Income Statement" (attached) or
2. A"Financial Statement" (attached(orb
3. A Copy of the person's current Federal income Tax Return
Failure to file, according to the Miami-Dade County Code Chapter 1, General Provision,
Section 1-5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment
in the county jail for a period not to exceed sixty days, or both.
.
a,44
Signature: Date:
FACLERULLWORMSIBOARD AND COMMn i EESIBC Apptication.doc