Patricia Fuller ApplicationCITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
FullerPatriciaG
NAME:
First Name
Last NameMiddle Initial
FL33139
HOME ADDRESS
:
2051577 Bay RdMiami Beach
Home No./StreetState
Apt No.City
Zip Code
pgfuller@earthlink.net
617.759.5657
PHONE
:
WorkEmail Address
HomeFax
Business Name:
retired
Position:
Miami BeachFL
Address:
State
No.
CityZip Code
Street
Expires:
Attach a copy the license
Professsional License (describe):
Pursuant to City Code section 2-22(4) a and b:
Members of agencies, boards, and committees shall be affiliated
requirement shall be fulfilled in the following ways: a) an indi
months; or b) an individual shall demonstrate ownership/interest
Yes
No
Yes
South Beach
circle one): I am now a resident of:
please see resume uploaded
No
123Please note that only three (3)
Please list your preferences in order of ranking [] first choice [] second choice, and [] third choice.
choices will be observed by the City Clerks Office.
(Regular Boards of City)
Affordable Housing Advisory CommitteeLoan Review Committee
[1]Art in Public Places CommitteeMarine Authority
Beautification CommitteeMiami Beach Commission for Women
Board of Adjustment*Miami Beach Cultural Arts Council
Budget Advisory CommitteeMiami Beach Human Rights Committee
Capital Improvements Projects Oversight CommitteeMiami Beach Sister Cities Program
Committee for Quality Education in MBNormandy Shores Local Govt Neigh. Improvement
Committee on the HomelessParks and Recreation Facilities Board
Community Development AdvisoryPersonnel Board
Community Relations BoardPlanning Board*
Convention Center Advisory BoardPolice Citizens Relations Committee
Debarment CommitteeProduction Industry Council
Design Review Board*Safety Committee
Disability Access CommitteeSingle Family Residential Review Panel
Fine Arts BoardSustainability Committee
Gay, Lesbian, Bisexual and Transgender (GLBT)Tennis Advisory Committee
Golf Advisory CommitteeTransportation and Parking Committee
Health Advisory CommitteeVisitor and Convention Authority
Health Facilities Authority BoardWaterfront Protection Committee
Hispanic Affairs CommitteeYouth Center Advisory Board
Historic Preservation BoardYouth Center Advisory Board
Housing Authority
Note
: If applying for Youth Advisory Board, please indicate your aff
1. Past service on the Youth Center Advisory Board:
No
Years of Service:
if yes, please list the names of your children, their
No
2. Present participation in Youth Center activities by your chil
ages, and which programs. List below:
Age:Program:
Child's name:
Age:Program:
Child's name:
No
Have you ever been convicted of a felony:If yes, please explain in detail:
Do you currently have a violation(s) of City of Miami Beach code
No
If yes, please explain in detail:
No
Do you currently owe the City of Money Beach any money:If yes, please explain in detail:
No
Are you currently serving on any City Boards or Committees:If yes, which board?
What organizations in the City of Miami Beach do you currently h
Miami Beach Community Dev't board member
Name:Title:
Corporation
Name:Title:
List all properties owned or have an interest in, which are loca
1577 Bay Rd, #205
No
I am now employed by the city of Miami Beach:Which department?
Pursuant to City code Section 2-25(b):
do you have a relative who is employed by the
City of Miami Beach? Check all that apply. Identify the departme
The following information is voluntary and is neither part of yo
being asked to comply with federal equal opportunity reporting r
Gender:Female
Ethnic Orgin: Check one only (1)
White
No
Physically Challenged:
Homemaker
Employment Status:
NOTEIf appointed, you will be required to follow certain laws which
:
These laws include, but are not limited to, the following:
Prohibition from directly or indirectly lobbying city personnel
o
Prohibition from contracting with the city (Miami-Dade County Co
o
Prohibition from lobbying before board/committee you have served
o
Beach Code section 2-26).
Requirement to disclose certain financial interests and gifts (M
o
(re: CMB Community Development Advisory Committee): prohibiti
from having any interest in or receiving any benefit from Co
or those with whom you have business or immediate family ties
Upon request, copies of these laws may be obtained from the
I hereby attest to the accuracy and truthfulness of the applica
VII of the City Code Standards of Conduct for City Officers,
I Patricia Fuller agreed to the following terms on 1/11/2013 2:0
Received in the City Clerk's Office by:Date: / /2013Control No.Date: / /2013
Name of Deputy Clerk