Carol Ann Housen ,.
„,
.1 AW I BEACH - - „,
CITY OF MiAMI BEeCH
BOARD AND COMMITTEE APPLICATION F 93M
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Last Name First Narne A/1/97/- Middle Initial i HOME ADDRESS: X 0O/ '/3-0 C9C•P.d-- iii „ e4
Apt No. • House No./Street / ��yl
,� City State Zip Code
PHONE:! d, . . f'o . -,-' , '6 3 i s �lo rj , . ,�_ )
Home ^� Work C Fax r Q/
Email address 'i
Business Name: Q�G / i%Oi&/4oson: G ,j • i■
Address: .tea • 20 X e = J
No. Street City - _ _S_ tate. 7 ,,� Zip Code ,':j
Professional License(describe) e04/7 ie ' /c4
F-xPir 'd� /��-Attach a copy of the Ita:nse
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/nterest for a minimum of six months in a business established in the city. .:
•Resident of Miami Beach for a minimum of six(6)months:Yeor No 0
•Demonstrate an ownership/interest in a business in Miami each for a minimum of six(6)months:Yes.*or No 0
•Are you a registered voter in Miami Beach:Yes 0 or No
•(Please circle one):I am now a resident of X North Beach South Beach Middle Beach i”
•I am applying for an appointment because I have s ecial bilities, owJe_dge n e •erience. Please list below: / '41L fe r',
•An?uou-presently T;°N Z. W rre4-5f4.a�-T {, / *C, - ti/CS
` Y p y reg lobb ist with e C of Miami��,"ach?Yes 0 or No ` ' -, i
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)
0 Affordable Housing Advisory Committee • ❑'Housing Authority
❑Art in Public Places Committee • - 0 Loan Review Committee • _ •
. . 0 Beautification Committee 0 Marine Authority
•0 Board of Adjustments •• 0 Miami Beach_Comrriission for Women- -- ,
[]Budget Advisory Committee-.-. --_ - - - 1,
0 Miami Beach Cultural Arts Council !
-ITCapital Improvements Projects Oversight Committee 0 Miami Beach.Sister Cities Program 1 r
❑Committee on the Homeless 0 Norm
• ''
0 Committee for Quality Education in MB . �dY Shores Local Government Neigh.Improvement ?I
0 Parks and Recreation Facilities Board il
0 Community Development Advisory ❑Personnel Board
❑Community Relations Board '1
❑Planning Board*
0 Convention Center Advisory Board - 0 Police Citizens Relations Committee 1�
0 Debarment Committee ,
❑Production Industry Council
Design Review Board* • 0 Public Safety Advisory Committee
0 Disability Access Committee . ;i
0 Fine Arts Board _0-Single Family Residential Review Panel i
0 Gay, Lesbian,Bisexual and Transgender(GLBT) • o Sustainabitity Committee `i
•0 Golf Advisory Committee • 0 Transportation and Parking Committee :
0 Health Advisory Committee :
0 Visitor and Convention Authority.
0 Health Facilities Authority Board ;i
❑Waber'iront Protection Committee
•
0 Hispanic Affairs Committee 0 Youth Center Advisory Board
0 Historic Preservation Board V
*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 0 No 0 Years of Service:
• 2. Present participation in Youth Center activities iv your children YesO No O. If yes, please list the names of.your�chil�lrek,., .
ages,and which programs.List below , t -
Child's name: .).}. ,
Age: Program: -:) }'ti s r1�. .h,Cil
Child's name: ., 1 c wit. :,
Age: Program: �. ;.�I y 1
Fr\CLER`SA.LL\eFORMS`BOARD AND C OMMATEES\BC Applicotiion0626OQ NEW.doc ' "�`'' d ���
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convicted of a felony:Yes" or - If yes, please explain in detail:
.•t;i�re you ever been con to es _
If yes, tease explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes o Y P P •
Y
F � If yes, explain in detail
• Do you currently owe the City of Miami Beach any money:Yes o`a5-=
•Are you currently
servin• on a City Boards or Committ s:Os or No,-... If yes;,which board?. .•
je - 4 c, , , -
•What organizations in the City of Miami Beach do you currently hold membership in?
..�i
' V' ' / , . e'l" ° Title:, 6 A-12,.�J I4t
Name: _ ...� C - Title: ' �! �' i
9 r ✓ ,ice oa •
Nam.. 1 �.� � ,.-<<
.. List all properties .wned or have an interest in,which are located within the City of Miami Beach:0/5'6 - S a C+ �U� -. r
• I am now employed by the City of Miami Beach:Yes D o oL ich department?
Code Section 2-25(b):Do you have a parent C,spouse 0,child 0,brother 0,or sister 0 who is employed by the
• Pursuant to C i ty
City of Miami Beach?Check all that apply.Identify the departrnent(s): it/ Aq
application nor has any bearing on your consideration for appointmerrt. It is and is neither part of your
The g ask following information comply i h federal qual opportunity reporting requirements.
being asked to comply with
Gender: O Male Female
thnic Origin: Check one only(1)
(Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe.North Africa or the Middle East
f� of the Black racial groups of Africa.
0 African-AmericanBiack (Not of Hispanic Origin):All persons having origins in any o
0 Hispanic: All persons of Mexican.Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin, of race.
on
of the original eo les of the Far East,Southeast❑Asian or Pacific Islander:All persons having origins In any peoples the Philippine islands and Somoa. - � -- �--
the Pacific Islands. This area includes,for example,China.India,Japan,Korea.
0 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 0 or Nq
Employment Status: Employed Retired 0 Homemaker 0 Other 0
NOTE: If appointed,you will be required to follow certain laws which apply to city boardlcommittee members.
These laws include,but are not limited to,the following:
o Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459).
o Prohibition from contracting with they(Miami-Dade u County
have served on for period of one year after leaving office (Miami
o Prohibition from lobbying before board/committee you Beach City Code section 2-26).
o Requirement to disclose certain financial interests and gifts(Miami Dad during ty Cod de and or one year after leaving office,
(re: CMB Community Development Advisory Committee): p
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 57 7 11)
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 the City Code"S ndards of Condu4J _)City Officers,Employees and Agency
• Gtr ' Date Name of Applicant(PLEASE PRINT)
nt's Signature d
Appluca 9 � /
Please-attach a copy of your resume to this application
NOTE:ApplicationswIIl:remain on file fora period of one(1)calendar year.
Date: /C 4 Control No. Date: 1 79/7'
C i on.doc
Received in the City Clerk's Office by Name of Deputy Clerk F:ICLER1$ALlAal-0NM \BOARD AND COMMITTEES\B APPS
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