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Jack D. Johnson Board Application and ResumeI � MIAMI ��-���M�AIB���H BOARD AND COMMITTEE APPLICATION FORM oLn 5 rin U4—e-k .12 Last Name. First Name Middle Initial Home Address City State - , Zip Code Home Telephone Work Telephone Cellular Telephone Email add ss jq Position: AMA Business Name AM Business Address City State Zip Code Professional License(describe) /I{ Expires: 41A 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�U or No • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six months: Yes or No • Are you a registered voter in Miami Beach: Yes M or No Ca • I am now a resident of: North Beach�J South Beach M Middle Beach • I am applying for an appointment because I have spe ipl abilities, knowledge and experience. Please list below: 4 t '00 nlano' Ix+en Sj Ve C40MMU111311 U21110heM4904- C 1 G • 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 ❑ Fine Arts Board ❑ Normandy Shores Local Government Neighborhood Improvement ❑Art in Public Places Committee ❑Gay, Lesbian, Bisexual and Transgender 0 Parks and Recreation Facilities Board Enhancement Committee GLBT ❑Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board ❑ Board of Adjustment* ❑ Health Advisory Committee t Planning 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 It ❑Safety Committee ❑Committee for Quality Education in MB ❑ Housing Authority ❑Single Fa ily Residential Review Panel 0 Community Development Advisory ❑ Loan Review Committee ❑Sustainability Committee ❑Community Relations Board 0 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: Typeof Professional License License Number NA F„I License Issuance Date N4 ,and License Expiration Date NA 90 :C Wd 82 330 110z U2AI e , F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc Note: If appl in for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board:Yes LJ No LJ Years of Service: 2. Present participation in Youth Center activities by your children Yes�D No�J. 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 or No If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes ZI or No LIPAA. If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes�l or No M If yes,explain in detail •Are you currently serving on any City Boards or Committees:Yes 4=3 or No M. If yes;which board? •What organizations in the City of Miami Beach do you currently hold membership in? _M ,eN1 w �,&Ach 6126 _ nard Ckol r Name Title e 4 o 04i Name Title • List all roperties owned,or have an interest in,which are located within the City of Miami Beach: 4f S • I am now employed by the City of Miami Beach:Yes I'D or No M.Which department? • Pursuant to City Code Section 2-25(b): Do you have a parent , spouse I,child�l brother ,or sister who is employed by the City of Miami Beach? Check all that apply. Identify the department(4 !Y 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 LAA 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. 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 throth tri bal affiliation or community recognition. Physically Challenged: Yes or No ZI Employment Status: Employed Retired Homemaker ZI 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 i 4M 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." I� 2 D S � o .4j,ice,,";2.A cant's SignatLW 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 Jack Johnson 831 Tenth St.,Apt. 5 Miami Beach,FL 33139 Home: 305-673-1267 Mobile: 305-606-0290 Objective Membership on a City Board (preferably the Planning Board)that will effectively utilize my knowledge and experience. Current Community Involvement Miami Beach Community Development Corporation, Board Chair Miami Design Preservation League, Board Member, Chair of Programs& Education Committee, Member of Executive Committee, Public Policy and Museum Committees Flamingo Park Neighborhood Association Miami Beach United South Beach Residences Condo Association(831 Tenth St.), Treasurer Employment Experience 33 years experience working with communities large and small on planning and community development issues. 1999—2003(retired) Director,Community Planning and Development U.S. Dept. Of Housing and Urban Development, Miami Office- Responsible for the administration and management of the CDBG, HOME and Homelessness programs in the ten counties of South Florida. Supervised a staff of 15 people and worked with Florida state, county and local governments to ensure proper program administration. 1971 - 1999 Various positions, Community Planning and Development U.S. Dept. Of Housing and Urban Development, New York Office—Positions included (from most recent to oldest) Deputy CPD Director, Program Manager for New York City programs, Regional Homelessness Coordinator, Economic Development Program Manr, CPD Representative. o C Education co 1972 Master of Divinity ,- Union Theological Seminary,New York,NY 1966 B.A.,Philosophy Texas Christian University, Fort Worth, Texas MIAMI BEACH City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.m iam i beachfl.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: T c k D ;.)hb o n 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. 2 Sig ture Date F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc