Board and Committee Application
BOARD AND COMMITTEE APPLICATION FORM
Last Name First Name Middle Initial
Home Address City State Zip Code
Home Telephone WorkTelephone Cellular Telephone Email address
Business NameOccupation
Business Address City State Zip Code
Professional License (describe):Expires:
Please attach a copy of currently effectiveprofessional license.
Pursuant to City Code section 2-22(4)aMembers of agencies, boards and committees shall be affiliated with the
&b:
City. This requirement shall be fulfilled in the following ways: a. Anindividual 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.
YesNo
ch for a minimum of six (6) months: or
YesNo
sownership/interest in a business in Miami Beach for a minimum of sixmonths: or
YesNo
or
North BeachSouth BeachMiddle Beach
I am now a resident of:
Please list below:
YesNo
City of Miami Beach? or
123Please note that
Please list your preferences in order of ranking [] first choice [] second choice, and [] third choice.
only three (3) choices will be observed by the City Clerk’s Office.
Ad Hoc Committee Centennial CelebrationHealth Advisory Committee
Parks and Recreation Facilities Board
Affordable Housing Advisory CommitteeHealth Facilities Authority BoardPersonnel Board
Art in Public Places CommitteeHispanic Affairs Committee Planning Board
Board of Adjustment *Historic Preservation BoardPolice Citizens Relations Committee
Budget Advisory CommitteeHousing AuthorityProduction Industry Council
Committee on the HomelessMarine & Waterfront Protection AuthoritySustainability Committee
Committee for Quality Education in MBMiami Beach Commission for Women Transportation, Parking, &Bicycle-Pedestrian
Facilities Committee
Convention Center Advisory BoardMiami Beach Cultural Arts Council Visitor and Convention Authority
Design Review Board*Miami Beach Human Rights Committee
Disability Access CommitteeMiami Beach Sister Cities Program
Gay, Lesbian, Bisexual and Transgender Normandy Shores Local Government
Enhancement Committee (GLBT)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 Boardor Planning Board, attach a copy of your currently-effectively license, and furnish the
following information:
Type of Professional License______________________________ LicenseNumber__________________________________
License IssuanceDate___________________________________ License Expiration Date____________________________
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Note
: If applying fortheYouth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with
the Scott Rakow Youth Centerand/or the North Shore Parks Youth Center:___________________________________________
___________________________________________________________________________________________________
____
Please describe your past service with the City’s Youth Centers (include dates of service):_______________________________
_______________________________________________________________________________________________________
Present participation in Youth Center activities by your children:YesNo
If yes, please listbelow the names of your children, their ages and theprogramsin which they participate:
Child’s name: ________________________________________ Age: ______ Program: _________________________________
Child’s name: ________________________________________Age: ______ Program: _________________________________
YesNo
Haveyou ever been convicted of a felony?or If yes, please explain in detail:
YesNo
o you currently have a violation(s) of City of Miami BeachCode?or If yes, please explain indetail:
_________________________________________________________________________________________________________________________________________________________________________________________________
YesNo
o you currently owe the City of Miami Beach any money?or If yes, explain in detail:
___________________________________________________________________________________________________________
YesNo
re you currently serving on any City Boardor Committee?or If yes,which board/committee?
___________________________________________________________________________________________________________
In what organization(s)in the City of Miami Beach do you currently hold membership?
___________________________________________________________________________________________________________
Name Position
___________________________________________________________________________________________________________
Name Position
List all properties owned orin which you have aninterest withinthe City of Miami Beach:
_________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________
YesNo
Are younow employed by the City of Miami Beach?or
Which departmentand title? ________________________________________________________________________________
Pursuant to City Code Section 2-25 (b):
Do you have a parent , spouse , child brother or sister who is
employed by the City of Miami Beach?Check all that apply.
If “Yes,” identify person(s)anddepartment(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 Female
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White
Asian or Pacific Islander
Native-American/American Indian
Other –Print Race:
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Do you consider yourself to be Spanish, Hispanic or Latino/a?
Mark the box if Spanish, Hispanic, Latino/a.
“No”not
No
Yes
Do you consider yourself Physically Disabled?
No
Yes
NOTE:IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THATAPPLY TO CITY BOARD/COMMITTEE
MEMBERS.THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO:
Prohibition from directly or indirectly lobbyingCity personnel (Miami Beach City Code section 2-459).
o
Prohibition from contracting with the City (Miami-Dade County Code section 2-11.1).
o
Prohibition from lobbying before the board/committee you have served on for period of one year after leaving office (Miami Beach
o
City Code section 2-26).
Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
o
CMB Community Development Advisory Committee:prohibition, during tenure and for one year after leaving office, fromhaving
o
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
o
of the Florida Statutes. These statutes establish a basic right of access to most
government can be found in Chapter 286
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, cityor other local level of government on an appointed or
o
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;ANDIHAVE RECEIVED, READ AND
WILL ABIDE BY CHAPTER 2, ARTICLE VII, OF THEMIAMI BEACHCITY CODE, ENTITLED“STANDARDS OF CONDUCT FOR
CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERSAND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
STATUTES ACCORDINGLY.”
_________________________________________________________________________________________________________________________
Applicant’s Signature Date Name of Applicant (PLEASE PRINT)
Received in the City Clerk’s Office by : ____________________________________________________________________________
Name of Deputy Clerk Control No. Date
PLEASEATTACH A CURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY
APPLICABLE PROFESSIONAL LICENSE.
ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED
INFORMATION.
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City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERKS OFFICE CityClerk@miamibeachfl.gov
Telephone: 305.673.7411 Fax: 305.673.7254
Acknowledgement of fines/suspension for Board/CommitteeMembers for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
Board Member’s Name
:
July 1, of each year
I understand that no later than 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 theymay have been recently appointed.
Onemust be filed
of the following forms with the City Clerk of Miami Beach, 1700 Convention Center Drive,
July1,ofeachyear.
Miami Beach, Florida, nolaterthan12:00noonof
1.A “Source of Income Statement”
2.A “Statement of Financial Interests (Form 1)”
3. A Copy of your latestFederal 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.
_______________________________________________________________________________________
Signature Date
Updated: Monday, June 02, 2014
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