Megan Riley Application package pending photo and resume ._ .
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m 1 Ami BEAc H CITY OF MIAMI BEACH
BOARDS AND COMMITTEE APPLICATION FORM
NAME: 1
Et Name ik N41/111 4 'Initial
HOME ADDRESS: c401W1 'LP Mv 4 IX&� �3/3 lçO City State Zip Code
No. Street y p
PHONE: 1 (e)."1 �cZ
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Home Work Fax Email address
Business Name: /3)(,6 m,u9cuyk, AIA Position: 17t pv Oderkal t
Address: b 0 & I ( L t c pi*J1 \ � 23/..3i No 44%06 15 -ete?
No. Street I 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: YessAor No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months:Yec or No ❑
•Are you a registered voter in Miami Beach:Yes ]or No ❑
• (Please check 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,experience. Please list below:
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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 Art in Public Places Committee ❑Housing Authority*
0 each Preservation Board ❑Loan Review Committee*
❑Beautification Committee 0 Mayor's Green Ad-Hoc Committee
❑Board of Adjustment* ❑Marine Authority* CD
❑Budget Advisory Committee 0 Miami Beach Cultural Arts Council -E �,-, �«
❑Committee on Homeless ❑Miami Beach Commission on Status of Women ` "
O Committee for Quality Education in MB 0 Miami Beach Florida Sister Cities n= a ��
❑Community Development Advisory* 0 Normandy Shores Local Gov't Neigh. Improvement 9 '�
0 Community Relations Board ❑Oversight Committee for General Obligation Bond
0 Convention Center Advisory Board 0 Parks and Recreation Facilities Board cn --u .,"o
0 Debarment Committee 0 Personnel Board* r_�' 0`"
❑Design Review Board* 0 Planning Board* • --T-1 r-
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0 Disability Access Committee ❑Police Citizens Relations Committee c ---
❑Fine Arts Board 0 Production Industry Council co
❑Golf Advisory Committee 0 Public Safety Advisory Committee
0 Health Advisory Committee 0 Safety Committee
0 Health Facilities Authority Board ❑Transportation and Parking Committee
0 Hispanic Affairs Committee 0 Visitor and Convention Authority*
0 Historic Preservation Board* ❑Youth Center Advisory Board
*Board Required to File State Disclosure form
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C:,Documents and Settingstcompurbm\Local Settings\Temporary Internet Files1OLK1 C5\SC Application Revised July 18 2007.doc
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❑No LI Years of Service:
2. Present participation in Youth Center activities by your children Yes❑ No ❑. 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:
•Have you ever been convicted of a felony: Yes❑or NoX If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes❑or No
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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:Ye ❑or No D. If yes;which board?
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•What organizations in the City of Miami Beach do you currently hold membership in?
Name: 1411Pc Title:
Name: tit k Title:
• List all properties owned or have an interest in,which are located within the City of Miami Beach:
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• I am now employed by the City of Miami Beach: Yes 0 or No i.Which department?
• 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. Identify the department(s):
This section is"not required"but desired:Age: years old Gender: Male❑ Female❑
Ethnic Origin (Check one)
White❑African-American/Black❑Hispanic: ❑Asian or Pacific Islander❑American Indian or Alaskan Native❑
Employment Status: Employed❑Retired❑Home-maker❑Other❑
"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"Standards of Conduct for City Officers, Employees and Agency Members."
7/ e g4ii Ir l 1
Applican s Sig 'tire Da a Name of Applicant(PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE:Applications will remain on file for a period of one(1)calendar year.
Received in City Clerk's Office by Date
Name of Deputy Clerk
Document Control Number(Assigned by the City Clerk's Office) Entered By Date
Revised 1/25/07 jo
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C:1Documents and Settingsicompurbrn\Local SettingslTemporary Internet Files\OLK1C5\BC Application Revised July 18 2007.doc