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Jack D Johnson Application Package MIAMI BEACK BOARD AND COMMITTEE APPLICATI®N FORM Last Name First Name Middle Initial 157-L J1111 FL'/14N a3 132 Home Address City State Zip Code CDC Home Telephone Work Telephone Cellular Telephone JEfnail addres Bus' ess 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 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 M or No • Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes E-D or No W •Are you a registered voter in Miami Beach: Yes M or No • I am now a resident of: North Beach IZI South Beach IM Middle Beach • I am applying for an appointment because I have special abilities, knowled a al experience. Please list below: r.s �2 e q h gl L34>a 3 •Are you presently a registered lobbyist with the City of Miami Beach?Yes[:1 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. 0 Ad Hoc Committee Centennial Celebration ❑Health Advisory Committee ❑Parks and Recreation Facilities Board°O ❑Affordable Housing Advisory Committee ❑Health Facilities Authority Board ❑Personnel Board ❑Art in Public Places Committee ❑Hispanic Affairs Committee Planning Board ❑Board of Adjustment* ❑Historic Preservation Board ❑Police Citizens Relations Committee ❑Budget Advisory Committee ❑Housing Authority - ❑Production Industry Council ❑Committee on the Homeless ❑Marine&Waterfront Protection Authority ❑Sustainability Committee 0 Committee for Quality Education in MB ❑Miami Beach Commission for Women ❑Transportation,Parking,&Bicycle-Pedestrian Facilities Committee 0 Convention Center Advisory Board ❑Miami Beach Cultural Arts Council ❑Visitor and Convention Authority 0 Design Review Board* ❑Miami Beach Human Rights Committee 0 Disability Access Committee ❑Miami Beach Sister Cities Program 0 Gay,Lesbian,Bisexual and Transgender ❑Normandy Shores Local Government Enhancement Committee GLB Neighborhood Improvement * Board members are required to file Form 1 -"Statement of Financial Interest"with the State. *If you seek appointment to a professional seat(e.g., lawyer, architect, etc.) 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 License Expiration Date Page 1 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx °O Note: If applying for the Youth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with the Scott Rakow Youth Center and/or the North Shore Parks Youth Center: Ah • Please describe your past service with the City's Youth Centers(include dates of service): • Present participation in Youth Center activities by your children..Yes �: i No If yes, please list below the names of your children,their ages and the programs in which they participate: Child's name: Age: Program: Child's name: Age: Program: • Have you ever been convicted of a felony?Yes : l or No LAA If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach Code?Yes Z)or NM 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 Cit Board or Committee?Yes or No If yes,which board/committee? • In what organization(s)in the City of Miami Beach do you currently hold membership? AG,4,mi C- _Z_ Ghder E,met; ��rS Nqgie Position I --- q'/nS 4h4 Name j Pbsition 4eC4 • List all properties owned or in which you have an interest within the City of Miami Beach: ,0 win - 031 10 4- ao •Are you now employed by the City of Miami Beach?Yes[.-=-a or No Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent --f, spouse 1—D, child ED brother EZt or sister 4Z who is employed by the City of Miami Beach?Check all that apply. A/ n 4 If"Yes," identify person(s)and 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 City diversity reporting requirements. Gender: Male IM Female Race/Ethnic Categories What is your race? ZI African-American/Black Caucasian/White Asian or Pacific Islander I�Native-American/American Indian I Other—Print Race: Page 2 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a. LAA No Yes Do you consider yourself Physically Disabled? M No Zh 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). • 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. 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 MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS,EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND _ STATUTES ACCORDINGLY." T G S plicant's Signat ate Name of Applicant(PLEASE PRINT) Received in the City Clerk's Office by Name of Deputy Clerk Control No. Date PLEASE 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 REVISED.docx MIAMI BEACH City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.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: J2 2� h So Y 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" 2. A "Statement of Financial Interests (Form 1)" 3. A Copy of your latest 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. /l nature Date I Updated:Monday,June 02,2014 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx Jack Johnson 831 Tenth St.,Apt. 5 Miami Beach,FL 33139 Hone: 305-673-1267 Mobile: 305-606-0290 Objective Reappointment to a second term on the Planning Board. Current Comm ni Involvement. u Miami Beach Community Development Corporation,Board Chair Emeritus Miami Design Preservation League,Board Member, Chair of Programs& Education Committee, Member of Executive Committee Flo Park Neighborhood Association Miami Beach United South Beach Residences Condo Association(831 Tenth St.),Treasurer EEm 1p o anent Ezaerience 32 years experience working with communities large and small on planning and community development issues. 1999—2003 (retired) Director,Community Planning and Development U.S. Dept. Of Housing and Urban Development, Miami Office- Responsible for the administration and management of the CDBG,HOME and Homelessness programs in the ten counties of South Florida. Supervised a staff of 15 people and worked with Florida state, county and local governments to ensure proper program administration. - 1971 -1999 Various positions,Community Planning and Development U.S. Dept. Of Housing and Urban Development, New York Office—Positions included (from most recent to oldest)Deputy CPD Director,Program Manager for New York City programs, Regional Homelessness Coordinator,Economic Development Program Manager, CPD Representative. Education 1972 Master of Divinity Union Theological Seminary,New York,NY 1966 B.A.,Philosophy Texas Christian University,Fort Worth,Texas i :. . . .. . . .. . . . .. . . . . . .. . .. .., :� �. - 1 2m w m yz! ?< , . . . . . : e . . ER�TENSE CLASS\©~ . a y . y J525-424- \® © } \ \JACK DWAYNE 2 . . . . �NSON y> . w. : . } ° . . \ \ e3i io S APT © : ; » g � : ± ! ° « MIBEACK, . : - . -