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William R. Cahill CITY OF MIAMi BEACH MIAMI H BOARD AND COMMITTEE APPLICA.ION FOR-Ail Last Name First Name d �Initial GI -t ®C&wA r &11 4 �L �3 � � C A IM Home Address City State Zip Code r `-7 7G 312_ Home Telephone Work Telephone Cellular Telephone Email ddress Ud1: 4-x-8( �*� �a5"f 6ugid Position: Mu&S 3.46 ,rVC4 1 ,�0-t f Business Name o& loc kr Business Address p�//City State Zip Code Professional License(describe) Ea �eeC 4L,44 e1 er uo °4 k v`d LV Expires: e,Vr"+ Attach a copy of the license G .t GJA_ fix 5"1 C01&rLC b 09C"er Pursuant to-City-Code section 2m22(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 for a minimum of six months. • Resident of Miami Beach for a minimum of six(6) months: Yes or No U • Demonstrate an ownership/interest in a business in mi Beach for a minimum of six months:Yes or No, •Are you a registered voter in Miami Beach: Yes or No U • I am now a resident of: North Beach L2rsouth Beach D Middle Beach • I am applying for an appointment because I ve special abilities, knowledge and experience. Please list below: 9J a� (i o . .tP M i -�-��•l co��t 6 c Fr�.�� I e., /fit �I v=��t •Are you presently a registered lobbyist with the City of Miami Beach?Yes LJor 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 ❑Disability Access Committee ❑Miami Beach Sister Cities Program ❑Art in Public Places Committee ❑ Fine Arts Board ❑Normandy Shores Local Government Neighborhood Improvement ❑ Beautification Committee ❑Gay, Lesbian, Bisexual and Transgender 0 Parks and Recreation Facilities Board Enhancement Committee GLBT 0 Board of Adjustment* ❑Golf Advisory Committee 0 Personnel Board 0 Budget Advisory Committee ❑ Health Advisory Committee 0 Planning Board" ❑Capital Improvements Projects ❑ Health Facilities Authority Board 0 Police Citizens Relations Committee Oversight Committee ❑ Committee on the Homeless ❑ Hispanic Affairs Committee 0 Production Industry Council 0 Committee for Quali Education in MB ❑ Historic Preservation Board B,Safety Committee ❑ Community Development Advisory ❑ Housing Authority 0 Single Family Residential Review Panel 0 Community Relations Board ❑ Loan Review Committee 0 Sustainability Committee ❑Convention Center Advisory Board Marine Authority ❑Tennis Advisory Committee ❑ Debarment Committee ❑ Miami Beach Commission for Women ❑Transportation and Parking Committee ❑ Design Review Board* ❑Miami Beach Cultural Arts Council ❑Visitor and Convention Authority ❑ Disability Access Committee ❑Miami Beach Human Rights Com ittee 0 Youth Center Advisory Board *Board Required to File State Disclosure Form AIA 44-o-.-J Pro,{ez Hof kg 4e x6cve 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 LA Years of Service: 2. Present participation in Youth Center activities by your children Yes �.'11i ye_t k ase ilist-tth�en ��pp�s of our children, No �f p ._- �,�1� Y their ages,and which programs. List below: Child's name: Age: Prod rn; dJS Child's name: Age: r Program: 1101 FACLER\$ALL''\aFORMS\BOARD AND C0MkViTTEES\BC Application.doc w, •Have you ever been convicted of a felony:Yes or No If yes,please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes�_.]or No . If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes 1-:1 or No Ulf yes, explain in detail •Are you currently serving on any City Boards or Committees:Yes�J or No 5-3.1f 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 I cated within the Gity f Miami Beach: • I am now employed by the City of Miami Beach:Yes U or No ZA.-W ich department? • Pursuant to City Code Section 2-25(b): Do you have a parent 1I1,spouse U,child brother�,or sister 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. Ethnic Origin: Check one onl 1) Gender: Male ZI Female 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. ZIAsian or Pacific Islander:All persons having origins in any of the original peoples of the Far East,Southeast Asia,the Indian Subcontinent,or the Pacific Islands. This area includes,for example,China,India,Japan,Korea,the Philippine Islands and Somoa. LDAmerican Indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain Cultural identification throu h tribal affiliation or community recognition. Physically Challenged: Yes or No Employment Status:Employed U5--- Retired ID Homemaker 1:1 Other C NOTE: IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/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). • 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). • 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, ARTICLE VII — OF THE CITY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYE D AGENC ME BERS." 25 Z Nr Ck l Applicanfs Kgrature Date ame of A plicant(PLEASE PRINT) Received in the City lerk's Office b -G �-�7 6 Y Y Name of Deputy Clerkf Control No. Date M,I A�-A I B EAC H City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK'S OFFICE CityClerk @miamibeachfl.gov Telephone: 305.673.7411 Fax: 305.673.7254 Acknowledgement of fines/suspension for Board Members for failure to comply with Miami-Dade County-Financial-Disclosure Code Provision Code Section--2-11.1(i)-(2)--- - - - - - ---- I// Board Member's Name: N o 1( lf Coy //r l r 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); or 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. Signature Date F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc