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Lori Gold Application package pending photo S AA MI `' BOARD AND COMMITTEE APPLICATION FORM Last NAie First Name Middle Initial Lo 21 e \(- \ -; tr--) Home Address Ci State e Zip Code ?� �X1 A--vQ I �� - -{ ( 111-4_1n\ �± EL7 -E-6. I c r(so I d a,e) Home Telephone Work Telephone Cellular Telephone Email address CD.S- 53 - U -j ds(Q 'j 1 v - '7 17'4l z-/ Business Name Occupatio /v/4 Lek t C 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 Lor No • Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes or No •Are you a registered voter in Miami Beach: Yes Zor No, • I am now a resident of: North Beach South Beach Middle Beach • I am applying for an poi ent because I have special abilities, knowle ge and experience. Please list below: i) . c r �'co e 75 crm?I Li c 5 I Vpa�.X d 5 G-A ( -5 ems K'r* e A \ c��w ei< S ch c� c C)�- •Are you presently a registered lobbyist with the City of Miami Beach?Yes or No r-` ' 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. ❑Ad Hoc Committee Centennial Celebration ❑Health Advisory Committee 0 Parks and Recreation Facilities Board oo ❑Affordable Housing Advisory Committee ❑Health Facilities Authority Board gef<sonnel Board ❑Art in Public Places Committee ❑Hispanic Affairs Committee ❑P.anriing Board ❑Board of Adjustment* * ❑Historic Preservation Board olice Citizens Relations Committee ❑Budget Advisory Committee ❑Housing Authority ❑Production Industry Council ❑Committee on the Homeless ❑Marine&Waterfront Protection Authority ❑Sustainability Committee ❑Committee for Quality Education in MB ❑Miami Beach Commission for Women ❑Transportation,Parking,&Bicycle-Pedestrian Facilities Committee ❑Convention Center Advisory Board ❑M mi Beach Cultural Arts Council ❑Visitor and Convention Authority ❑Design Review Board** 2'Miami Beach Human Rights Committee ❑Disability Access Committee ©Miami 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 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 r_ L °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: • 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 LI No L 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 or No Er If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach Code?Yes Ui or No' -.V If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money?Yes Ui or No IIf yes, explain in detail: •Are you currently serving on any City Board or Committee?Yes Zior No IZI1 If yes,which board/committee? feAr50 n n e i • In what organization(s)in the City of Miami Beach do you currently hold membership? R-PUQIY\ A,55N ', CatZQA5 VcAC---e-- '-a,c-ac4 Na Po ition uvvi Lea,c�►�� , Q Ate _c��m Name Position • List all properties owned or in which you have an interest within the City of Miami Beach: 0,0v\dt rn'v lM l U Yv\ un w l c..k ■ \% ✓t •Are you now employed by the City of Miami Beach?Yes or No L Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent Ui, spouse Li, child brother Di or sister 1=3 who is employed by the City of Miami Beach?Check all that apply. If"Yes,"identify person(s)and department(s): NJ 0 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 Lr Race/Ethnic Categories What is your race? ' A frican-American/Black Caucasian,White I t, 4�!Asian or Pacific Islander II-1�,I Native-American/American Indian II 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. I 81 No ZliYes �Doyou consider yourself Physically Disabled? 4No 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: o Prohibition from directly or indirectly lobbying City 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 City Code section 2-26). o 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, 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). o 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. o 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." vim; 040( l� i L cz.1 Cr a A lic is Signatu Da 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 F.. f . 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: 1--O 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. 10 /(6— o(._ 'g natu Date Updated:Monday,June 02,2014 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx LORI GOLD, J.D., M.S. 3 ISLAND AVENUE, PH-H MIAMI BEACH, FL 33139 Mobile: (786) 390-7444 ttlorigold @aol.com EDUCATION: B.A., 1963, QUEENS COLLEGE,UNIV. OF CITY OF N.Y. M.S.IN EDUCATION, 1965, CITY COLLEGE,UNIV. OF CITY OF N.Y. J.D., 1983,EMORY UNIVERSITY,ATLANTA, GA. PROFESSIONAL WORK EXPERIENCE: SCHOOL PSYCHOMETRIST,DIRECTOR OF ELEMENTARY SCHOOL GUIDANCE PROGRAM,TEACHER ATTORNEY,RETIRED MEMBER OF THE GEORGIA BAR EXECUTIVE DIRECTOR GEORGIA PROFESSIONAL LICENSING BOARDS DIVORCE MEDIATOR RECOGNITION& HONORS: 2006 MIAMI BEACH KIWANIAN OF THE YEAR 1981 WHO'S WHO IN AMERICAN WOMEN 1980 LEADERSHIP ATLANTA COMMUNITY LEADERSHIP ACTIVITIES (FLORIDA 1996-PRESENT) 2012-2013 MIAMI BEACH CITIZENS POLICE ACADEMY 2007-2008 COMMITTEE FOR QUALITY EDUCATION IN MIAMI BEACH 2006-PRESENT PRESIDENT,EESAC COMMITTEE, TREASURE ISLAND ELEMENTARY SCHOOL 2005-2006 MIAMI BEACH NEIGHBORHOOD LEADERSHIPACADEMY 2007--2008 SECRETARY,ALUMNI ASSOCIATION 2007 PRESIDENT ELECT,KIWANIS CLUB OF MIAMI BEACH 2006-PRESENT PRESIDENT,BOARD MEMBER,FAMILY COUNSELING SERVICES OF GREATER MIAMI & THE JOURNEY INSTITUTE, SWITCHBOARD MIAMI 1999-2004 TERRACE TOWERS CO-OP BOARD MEMBER; VICE PRESIDENT; CHAIR OF BYLAWS REVISION AND LEGAL MATTERS COMMITTEES 2013-PRESENT, MIAMI BEACH PERSONNEL BOARD COMMUNITY LEADERSHIP ACTIVITIES (GEORGIA 1969-1996) GEORGIA PUBLIC ACCESS TELEVISION,PRESIDENT 55 PHARR ROAD CONDOMINIUM ASSOCIATION,PRESIDENT (6 YEARS) AND MEMBER OF THAT BOARD FOR 8 YEARS BRANDEIS WOMENS COMMITTEE, CHAIR OF COMMITTEES ARTS FESTIVAL OF ATLANTA, CHAIR OF COMMITTEES NATIONAL COUNCIL OF JEWISH WOMEN,CHAIR OF COMMITTEES