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Daniel N. Sherbill 1 E CITY OF MIAMI BEACH MIANA1 BA "H ��- #c APPLICATION FORM 519t61L_L_ n 7ye,01. L/N S l ' /"B�OC� r!,M le Initial o A res ® �� or City State &Z n 1 H e Telep one Work Tele phone Cellular Telephone Emai address a �aQ Position: u iness Name cz +�5 + �. 'o Business Address City State tip t6de 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 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 Uor No Ca • Demonstrate an ownershi p/interest in a business in Miami Beach for a minimum of six months:Yes dr No ZI • Are you a registered voter in Miami Beach: Yes ED or No • I am now a resident of: North Beach 10 South Beach ED Middle Beach ID • I am applying for an ap ointment because I have special abilities k owledge and ex erience. Please list below: pV C14' .� • Are you presently a registered lobbyist with Ae City of Miami Beach?Yes or 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 Parks and Recreation Facilities Board Enhancement Committee GLBT Beautification Committee Golf Advisory Committee Personnel Board Board of Adjustment* Health Advisory Committee Planning Board* Budget Advisory Committee Health Facilities Authority Board Police Citizens Relations Committee Capital Improvements Projects Hispanic Affairs Committee Production Industry Council Oversi ht 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* `C 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: Type of Professional License License Number , License Issuance Date ,and License Expiration Date C:\Users\clerpris\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\5TS003ME\BC Application.doc 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 ID Years of Service: 2. Present participation in Youth Center activities by your children Yes E_J No ED. 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 ZIf es lease explain in detail: Y Y yes, � • Do you currently have a violations of City of Miami-Beach codes:Yes�or No - y y O y . If yes,-please explain-in detail: • Do you currently owe the City of Miami Beach any money:Yes or No If yes, explain in detail •Are you currently serving on any City Boards or Committees: Yes&Or No 1.2 If yes;which board? •What organizations in the City of Miami Beach do you currently hold membership in? RIC C- 6 C,7 6-5&�,g lyp Al 1-04 5E r,ke 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 Za or No Which department? • Pursuant to City Code Section 2-25(b): Do you have a parent ,spouse U,child U brother�.3,or sister Il 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:Ch ck one only 1) Ge er: Male Female ID White (Not of Hispanic Origin):All persons having origins in an of the original eo les of Europe,North Africa or the Middle East. P 9 Y peoples P 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 throw h tribal affiliation or community recognition. Physically Challenged: Yes ZI or No ZI Employment Status: Employed Retired 1.1 Homemaker U 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. C:\Users\clerpris\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\5TS003ME\BC Application.doc 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." le2 ;� 4<o .3 t- 5#,��P?Cd Iz- Applica 's ig Date Na a of Applicant(PLEASE PRINT) Received in the City Clerk's Office by Name of Deputy Cler1k Control N Qlate C:\Users\clerpris\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\5TS003ME\BC Application.doc