Daniel Veitia Application and License NA AM CITY OF MIAMI BEACH
/ BOARD AND COMMIT TEE.APPLIC,ATION FORM
Last Name First Name Middle Initial
Home Address City State Zip Code
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Home Telephone Work Telephone Cellular Telephone Email address
t//.So.;' /?-AS c r P Position: ®'•,.'e--z
Business Name
Business Address / / City State / f Zip Code
Professional License(describe) / c/�.C2 g.cr 4Ck.- 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 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 Oeor No
• Demonstrate an ownership/interest in a business in iami Beach for a minimum of six months: Yes r No
• Are ou registered voter in Miami Beac : Yes r No
Y g
• I am now a resident of: North Beach South Beach Middle Beach
• I am applying for an 5ppoin tment because I have special abilities, knowledge and experience. Please list below:
• Are esent) are registered lobbyist with the City of Miami Beach?Yes or No
e You presently 9 Y Y
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 ❑ Fine Arts Board ❑ Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee ❑ Gay, Lesbian, Bisexual and Transgender ❑ Parks and Recreation Facilities Board
Enhancement Committee GLBT
❑ Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board
❑Board of Adjustment* * ❑ Health Advisory Committee kil tinning Board**
❑Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Police Citizens Relations Committee
❑Capital Improvements Projects ❑ Hispanic Affairs Committee ❑ Production Industry Council
Oversight Committee
❑Committee on the Homeless ❑ Historic Preservation Board ❑Safety Committee
❑Committee for Quality Education in MB ❑ Housing Authority ❑Single Family Residential Review Panel
❑Community Development Advisory ❑Loan Review Committee ❑Sustainability Committee
❑Community Relations Board ❑ Marine Authority ❑Tennis Advisory Committee
❑Convention Center Advisory Board ❑ Miami Beach Commission for Women ❑Transportation and Parking Committee
❑ Debarment Committee ❑ Miami Beach Cultural Arts Council ❑Visitor and Convention Authority
❑ Design Review Board* ❑ Miami Beach Human Rights Committee ❑Youth Center Advisory Board
❑ Disability Access Committee ❑ Miami Beach Sister Cities Program ❑Waterfront Protection Committee
* Board Required to File State Disclosure Form
If you seek appointment to a professional seat(e.g., lawyer, architect)on the Board of Adjustment, Design Review Board,
Historic Preservation Board,or Planning Board, attach a copy of your currently-effectively license,and furnish the
following information: / p
Type of Professional License ��,•/ ,�sfo., X,,&4;, License Number A94 2
License Issuance Date z' A?Oi ,and License Expiration Date
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F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
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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 I.J No Years of Service:
2. Present participation in Youth Center activities by your children Yes No �]. 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:
*Have you ever been convicted of a felony:Yes ID or No If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes ID or No li If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes ZI or No U If yes, explain in detail
•Are you currently serving on any City Boards or Committees:Yes Z1 or No If yes;which board?
•What organizations in the Ciitty 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 Z3 or No Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent , spouse , child brother , or sister ID who is
employed by the City of Miami Beach? Check all that apply. Identify the department(s): 41
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:&Female k one only(1)
Gender: Male
White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
EZI scan-American/Black (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa.
YHispanic: 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,or
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 throu h tribal affili or community recognition.
d:
Physically Challenge Yes or No
Employment Status: Employed Retired 9 Homemaker Other
Please remember to attach a current resume and a copy of any applicable
professional license.
Attach additional sheets, if necessary, to provide required information.
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
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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 I HAVE RECEIVED, READ AND
WILL ABIDE BY CHAPTER 2, ARTICLE VII — OF THE CITY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS,
EMPLOYEES AND AGENCY MEMBERS."
Applican ' ure Date Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by
Name of Deputy Clerk Control No. Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
MIAMI
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)
Board Member's 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); 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.
Signat Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
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Daniel Veitia
1525 Normandy Drive
Miami Beach, FL 33141 ^,
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305-219-3408 =�
daniel @urbanresource.com C=
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Wednesday, December 05, 2012 o
Rafael E. Granado,City Clerk
City of Miami Beach
1700 Convention Center Drive
Miami Beach, FL 33139
Re: Re-Appointment to the Planning Board
I would first like to welcome you to the City of Miami Beach and congratulate you on your recent
appointment as our city clerk. I look forward to meeting you in person in the near future.
Thank you for providing me with the information regarding my re-appointment to Planning Board. As
requested, please find enclosed the completed application and a copy of my renewed license.
Please let me know if you require any additional information at this time.
Sincerely,
Daniel Veitia