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Francinelee Hand application package S M IA/ BOARD AND COMMITTEE APPLICATION FORM Last a rro First Name Middle Initial MP (1) --1;� C!t 1(0- e.--e_ Home Addres City State Zip Code �31 o 331 o Home Telephone Work Te phone Cellular Telephone Email a ress • /a tc—qVitee dee Business Name Occupation Business Address City State Zip Code '= Professional License(describe): Expires: Please attach a copy of currently effective professional license. Pursuant to City Code section 2-22(4)a & 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 mXNo of six months in a business established in the City for a minimum of six months. r • Resident of Miami Beach for a minimum of six (6) months: Yes • Demonstrates ownership/interest in a business in MW mi Beach for a minim f six months: Yes�or No • Are you a registered voter in Miami Beach: Yes or No y g • I am now a resident of: North Beach South Beach Middle Beach Gtr �3 • I am Wplying fqr an appointment because I have special abilities, knowledge anA experience. lease list below: S ' rt � r � • Are you prently a registered lobbyist ith the City o 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. ❑Ad Hoc Charter Review and Revision Board arment Committee ❑Miami Beach Human Rights Committee ❑Ad Hoc Committee Centennial Celebration sign Review Board* ❑Miami Beach Sister Cities Program ❑Ad Hoc Committee Flooding Task For isability Access Committee ❑Normandy Shores Local Government Neighborhood Improvement ffordable Housing Advisory Committee ❑Fine Arts Board ❑Parks and Recreation Facilities Board in Public Places Committee ❑Gay,Lesbian,Bisexual and Transgender ❑Personnel Board Enhancement Committee GLBT ❑Beautification Committee ❑Golf Advisory Committee ❑Planning Board ❑Bicycle-Pedestrian Advisory Committee ❑Health Advisory Committee ❑Police Citizens Relations Committee ❑Board of Adjustment* ❑Health Facilities Authority Board ❑Production Industry Council ❑Budget Advisory Committee ❑Hispanic Affairs Committee ❑Safety Committee ❑Capital Improvements Projects Oversight ❑Historic Preservation Board ❑Single Family Residential Review Panel Committee ❑Committee on the Homeless ❑Housing Authority ❑Sustainability Committee i ❑Committee for Quality Education in MB ❑Loan Review Committee ❑Tennis Advisory Committee ❑Community Development Advisory Committee ee a rin Authority ❑Transportation and Parking Committee ❑Community Relations Board Wiami Beach Commission for Women ❑Visitor and Convention Authority ❑Convention Center Advisory Board . Miami Beach Cultural Arts Council ❑Youth Center Advisory Board ❑Waterfront Protection Committee 90 =6 WV 91 330 NOZ :a` Page 1 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION 46 BOARDS 12092013.doc G oO Note: If applying for Youth Center 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 Dates of Service: 2. Present participation in Youth Center activities by your children:Yes LJ No L If yes, please list below the names of your children,their ages and the programs in which they pa cipat I Child's name: Age: Program: Child's name: e: Program: • Have you ever been convicted of a felony?Yes Lj or No 10 If yes, please explain in detail: . Do you currently have a violation(s)of City of Miami Beach Code?Yes U or N If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money?Yes U or Po 5j If yes,explain in detail: •Are you cur e ly sefiving on any City Board Co i ee?Yes Odor No U If yes,which board/committee? • 1 w a orga 'zation(s)i the City of Miami Beach do Vol] y hol membership? Tal s! 1&k Na n Name lJosition • Lis all properties owned or.in w i h hu have in rest within the City of Miami Beach: •Are you now employed by the City of Miami Beach?Yes U or No Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent U, spouse U, child U brother U or sister E-J who is employed by the City of Miami Beach?Check all that apply. If"Yes," identify person(s)and department(s):_ 1&;6 The following information is voluntary 9LRd is neither part of your application nor has any bearing on your'consideration for appointment. It is being asked to-co Moy with City diversity reporting requirements. Gender: Male I.J Female Race/Ethnic Categories What is your race? rican-American/Black Caucasian/White Asian or Pacific Islander Native-American/American Indian Other—Print Race: Page 2 of 4 F:ICLERI$ALL1aFORMSIBOARD AND COMMITTEESIBC APPLICATION 46 BOARDS 12092013.doc I YNo consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a. Yes Do you consider yourself Physically Disabled? Z'No Yes 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: • 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 the board/committee you have served on for period of one year after leaving office(Miami Beach City Code section 2-26). o 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). • Sunshine Law - Florida's Government-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most meetings of boards,commissions and other governing bodies of state and local governmental agencies or authorities. • Voting conflict—Form 8B is for use by any person serving at the county, city or other local level of government on an appointed or elected board, council, commission, authority or committee. It applies equally to members of advisory and non-advisory bodies who are presented with a voting conflict of interest under Section 112.3143, Florida Statutes. Upon request,copies of these laws may be obtained from the City Clerk. 1 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 MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBER AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACCORDINGLY." Q Applicant's Signature Date a e of Applicant(PLEASE PRINT) Received in the City lerk's Office b : Z 0 Y Y Name of Deputy Clerk Control No. Date PLEASE REMEMBER TO ATTACH A CURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY APPLICABLE PROFESSIONAL LICENSE. ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED INFORMATION. Page 3 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION 46 BOARDS 12092013.doc MIAN\1 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/Committee 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 Financial 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 they may have been recently appointed. One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, no later than 12:00 noon of July 1, of each year. 1. A"Source of Income Statement" For your convenience, the form is attached. The form can also be downloaded at: http://www.miamidade.gov/elections/Library/source of income statement.pdf 2. A "Statement of Financial Interests (Form 1)" For your convenience, the form is attached. The form can also be downloaded at: http://www.ethics.state.fl.us/ethics/forms.htmi 3. A Copy of your 2013 Federal Income Tax Return Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine of no more than $500, 60 days in jail or both. � 3 Signature ate Updated:Monday,December 09,2013 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION 46 BOARDS 12092013.doc 53►3 �o� �(�� a �t 193 A0411 BectLk) a&C'a, � i ,�rad - �ri�� 4� �t`rnit � �,�- t95- tv La Lt�k- q auy-5 -- ci", 61�z.. NN c�o .30 3 �I'��uloet/ .�fl coiu'c cQ..�a✓obrt C�.b - �la.� C'o•��v',J`�1 � ago.( Cua o� i�irtaS/`TOr�S �tgcly 4�e ,� �, �: i � - 4 .� �� •' tT