Joseph D. Conway Board application package F'
NAME:
Last Name First Name addle Initial
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Apt No. House No./Street City State Zip Code
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Business Name: .T�S� Position: � �`'��'� 4
Address:
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No. Street City State Zip Code
Professional License(describe) s`' �' Expires: u _
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.
• Resident of Miami Beach for a minimum of six(6)months:YesYr No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months:YesXor No ❑
•Are you a registered voter in Miami Beach:Yes Xr No ❑
•(Please circle one): I am now a resident of: North Beach odt B ch Middle Beach
• I am applying for an appointment because I have�special af �s know a gend e erience. Plead-list below: �� �,`-�
•AZ you presentka rregister2d lobbyist wit the City of Miami Beach?Yes❑or No �� ,/p2��
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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 0 Marine Authority
❑Art in Public Places Committee ❑Miami Beach Commission for Women
❑Beautification Committee ❑Miami Beach Cultural Arts Council
❑Board of Adjustment* ❑Miami Beach Human Rights Committee
❑Budget Advisory Committee ❑Miami Beach Sister Cities Program
❑Capital Improvements Projects Oversight Committee ❑Normandy Shores Local Government Neigh. Improvement
❑Committee on the Homeless XParks and Recreation Facilities Board
❑Committee for Quality Education in MB Personnel Board
❑Community Development Advisory ❑Planning Board*
❑Community Relations Board ❑Police Citizens Relations Committee
❑Convention Center Advisory Board ❑Production Industry Council
❑Debarment Committee ❑Public Safety Advisory Committee
❑Design Review Board* ❑Safety Committee
0 Disability Access Committee ❑Single Family Residential Review Panel
0 Fine Arts Board ❑Sustainability Committee
❑Gay, Lesbian, Bisexual and Trans ender GLBT 0 Transportation and Parking Committee
Golf Advisory Committee 0 Visitor and Convention Authority
❑Health Advisory Committee ❑Waterfront Protection Committee
❑Health Facilities Authority Board ❑Youth Center Advisory Board
❑Hispanic Affairs Committee
❑Historic Preservation Board
❑Housing Authority
❑Loan Review Committee *Board Required to File State Disclosure Form
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)Oo❑ 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 I I or No iX If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes: Yes ❑or NoX If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes❑or NoX. If yes, explain in detail
•Are you currently serving on any City Boards or Committees: Yes❑or NoX If yes;which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: /%I�i0�"I �;O"ey /wig.`,44s 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❑or NWhich department?
• Pursuant to City Code Section 2-25(b): Do you have a parent ❑, spouse—j, child!j, brother ], or sister 11 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.
Gender: Male ❑ Female
Ethnic Origin: Check one only(1)
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,on
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 through tribal affiliation or community recognition.
Physically Challenged: Yes❑or No❑.
Employment Status: Employed Retired❑ Homemaker❑ Other❑
NOTE: If appointed,you will be required to follow certain laws which 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).
(re: 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 have received, read and will abide by Chapter 2,
Article VII—of th gityMde"Standards of Conduct/for City Officers,Employees and Agency Members."
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Applicant's Sin re 7 Date f Nam6 of Applicant(PLEASE MINT)
Please Rattach a copy of your resume to this'application
NOTE:Applications/Pill:re ain on file for a period of one(1)calendar year:
Received in the City Clerk's Office by: Date. U 2010 Control N Date:_/_/2010 l
Name of Deputy Clerk
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D RIVER LICENSE CLASS E --
0500-484-5913074 .
_ JOSEPH D CONWAY -
140 JEFFERSON AVE#14009
i -MIAMI.BCH,FL 33139-7079:
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