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Sidney Goldin Board application packageI IAM I Q., 07Y OF t1lr6AMI BEACH �"'3�►ARD AND �OI�f� ;TT'EE APPLICATION FORM NAME: G_4�� L v c L Name. first Name Middle Initial HOME ADDRESS: l &r-A � 3 J 1` o Amt^o. House 'No./Street City State Zip Code PHONE: 1 6 :5 �b 611 Home Work Fax Email address Business Name: Position: Address: No. Street City State Zip Code 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. • Resident of Miami Beach for a minimum of six(6)months:Yes)Qr No ❑ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months: Yesr No ❑ •Are you a registered voter in Miami Beach: Yes Ar No ❑ • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowledge and experience. eas elow: •Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or NoX 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 ❑Housing Authority ❑Art in Public Places Committee ❑Loan Review Committee 0 Beautification Committee 0 Marine Authority 0 Board of Adjustment* ❑Miami.Beach Commission for Women 0 Budget Advisory Committee ❑Miami Beach Cultural Arts Council 0 Capital Improvements Projects Oversight Committee ❑Miami Beach Sister Cities Program 0 Committee on the Homeless 0 Normandy Shores Local Government Neigh. Improvement 0 Committee for Quality Education in MB ❑Parks and Recreation Facilities Board 0 Community Development Advisory ❑Personnel Board 0 Community Relations Board ❑Planning Board* 0 Convention Center Advisory Board 0 Police Citizens Relations Committee ❑Debarment Committee ❑Production Industry Council 0 Design Review Board* 0 Public Safety Advisory Committee 0 Disabilfty Access Committee 0 Safety Committee 0 Fine Arts Board 0 Single Family Residential Review Panel ❑Gay, Lesbian, Bisexual and Trans ender GLBT ❑Sustainability Committee 0 Golf Advisory Committee ❑Transparency Reliability&Accountability Committee"TRAC" ❑Health Advisory Committee ❑Transportation and Parking Committee ,WHealth Facilities Authority Board 0 Visitor and Convention Authority 0 is anic Affairs Committee 0 Waterfront Protection Committee ❑Historic Preservation Board 0 Youth Center Advisory Board *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 J No_ Years of Service. 2. Present participation in Youth Center activities by your children Yes-E No a 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: F:\CLER\$ALL\oFORMS\BOARD AND COMMITTEES\BC Application0626 9 NEW.doc / *Have you ever been convicted of ,iy: Yes or NoLIf yes, please explain il. _t. • Do you currently have a violation(s) of City of N(iaihii Beach codes: Yes `or NoA. 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 Noy If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name- Title: Name: Title: • List all properties owned or have n 2 terest in,which are located within the City of Miami Beach: • I am now employed by the City of Miami Beach: Yes Di or No'. Which department? • Pursuant to City Code Section 2-25(b): Do you have a parent C-, spouse`pi, child FE, brother!`l, or sister LD 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) *hlte (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 Ej 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 VI of a City Code "Stan d fQonduct for City O 'ceEmployees and Agency Members." !'Lz Ap ticant's Signatur Date Name of Applicant(PLEASE PRINT) P1b".*V taah=a:copyrdf�ouur-resume:to thisiapplication NOTE:';Appiicattons.will_. main on lle fora period of one(1):calendar year. Received in the City Clerk's Office by Date. (/ /12010 Control No. / Date: `_1!2010 Name of De uty Clerk F:ICLERI$ L1aFORMSIBOARD AND COMMITTEESIBC pplication.doc CIRRICULUM VITAE Name: Sidney Goldin Date of Birth: November 17, 1929 Place of Birth: Baltimore, Maryland Marital Status: Married Education: High School Diploma, 1949 Baltimore City College, Baltimore, Maryland Bachelor of Science in Business Administration, 1954 University of Baltimore, Baltimore, Maryland Registered Medical Record Administration, 1956 U.S.P.H.S. Hospital, Baltimore, Maryland Law School, 1956-60 University of Baltimore, School of Law Baltimore, Maryland Master of Hospital Administration, 1962 Medical College of Virginia Richmond, Virginia Resident of Hospital Administration, 1962 Mount Sinai Hospital Chicago, Illinois Work Experience: Assistant Director, Medical Record Dept., 1957-58 The Johns Hopkins Hospital, Baltimore, Maryland Executive Director, NIH Grant OM-92, 1959-60 Maryland State Department of Mental Hygiene, Baltimore, Maryland Administrative Assistant, July 1962 to July 1963 Assistant Director, July 1963 to February 1965 Mount Sinai Hospital, Miami Beach, Florida Associate Director, September 1966-December 1968 The Brookdale Hospital Center, Brooklyn, New York Assistant Director, December 1968 to May 1970 Associate Director, May 1970 to December 1980 Vice President, January 1981 to November 1995 Mount Sinai Medical Center, Miami Beach, Florida Current Organizations: Board of Directors Miami Beach Chamber of Commerce, 1990 to Present Miami Jewish Home and Hospital, 1996 to Present DeHoernle Alzheimer Pavilion, 1998 to Present Previous Committees: Beach Preservation Board City of Miami Beach Police Citizens Relations Committee Visitors and Convention Authority Health Facilities Authority Board