Carol Housen Application package pending photo and resume . ,
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BOARD AND COMMITTEE APPLICATION FORM
Last Name First Name Middle Initial
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Home Address City State Zip Code
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Home Telephone Work Telep one Cellular Telephone Email address / Co#1
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Business Name Occupation
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Business Address c ,�' # City tate Zip Co e
Professional License(describe): 2 1.��--5/CZ/i terD,e-e/ Expires: M6.r-e_/ c'26 1415-
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: Ye or No
• Demonstrates ownership/interest in a business in Miami Beac for a minimum of six months: Yes 7I or No
•Are you a registered voter in Miami Beac : Yes pi or No
• I am now a resident of: North Beach ., South Beach I, __II Middle Beach . .nil
_
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
ie Are you presently a registered lobbyist with the City of Miami Beach?N'es 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.
❑Ad Hoc Committee Centennial Celebration ❑Health Advisory Committee
0 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* * ❑ istoric Preservation Board * ❑Police Citizens Relations Committee
❑Budget Advisory Committee ousing 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 ❑Miami Beach Cultural Arts Council ❑Visitor and Convention Authority
' esign Review Board*- ❑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:
la PA
Type of Professional License I4 6 r Q!-e .0 f dZi e e umber l� ®,5- 6
License Issuance Date ira /”3 3 License Expiration Date .3/Z 0(5
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°° Note: If applying for the -: th Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with
the Scott Rakow Youth Cent- and/or the North Shore Parks Youth Center:
• Please describe your past service with th_ City's Youth Center include dates of service):
• Present participation in Youth Center activities •' you hildren:Yes ZJI No
If yes, please list below the names of y.. children,their ag- and the programs in which they participate:
Child's name: A. : Program:
Child's name: Age: Program: , _
• Have you ever been convicted of a felony?Yes LII or No If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach Code?Yes Eli or NoLlf yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money?Yes 4J1 or No rvi If yes, explain in detail:
•Are you currently serving on any City Board or Committee?Yes or No 171 If yes,whit board/c mmittee?
po iK d v
• In what organization(s)in the City of Miami Beach do you currently hold membership?
2 .i b ft eAirm-aqv - ,. e /5
Name / Po ition p , ,/ ,1 f _co l G 3)_
Name Position
• List all properties wned or in which you have an interest within the City of Miami Beach:
7330 5re Y e6 / •1 rile -33/W
o s r �=q 3-p' ,i,-,76/, /97 33,9, 0/5 6 9sr ///, /o_ ,3 X57
•Are you now employed by the City of Miami Beach?Yes I- -li or No Itr
Which department and title? /V A
• Pursuant to City Code Section 2-25 (b): Do you have a parent la spouse Li, child Li brother Li or sister Li who is
employed by the City of Miami Beach?Check all that apply.
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�bbeing asked to comply with City diversity reporting requirements.
I —
4-
Gender: Male �i Female°Ai
Race/Ethnic Categories
What is your race?
African-American/Black
`1 Caucasian/White
i Asian or Pacific Islander
Iii Native-American/American Indian
Li Other—Print Race:
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Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the"No"box if not Spanish, Hispanic, Latino/a.
.t=4.1 No
Yes
Do you consider yourself Physically Disabled?
No
Yes C. y rt..)
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."
•
*e'. 7 I /1/209-)/5 �� Ate/ fid rise
Applicant's Signature Date N me of A nt(PLEASE PRIN
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.
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MIAMI
.i EACL-1
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www..m i a m i b ea c h fl.9 ov
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: a r O / Ah S -a-A)
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.
/ 1 OA , -
/' //!.// A 1 /
Signature 9-:te
Updated: Monday,June 02,2014
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