Richard Cuello-Fuentes Application Package ( Z /o / i-1
tral /\/\JL\/\/\ j BF'\( F CITY OF MIAMI REACH
BOARDS AND COMMITTEE APPLICATION FORM
NAME: Cuello-Fuentes Richard
Last Name First Name Middle Initial
HOME ADDRESS: 888 Brickel Key Drive '3t9't Z Miami FL 33131
No. Street City State Zip Code
PHONE: 305-776-7831 305-532-8355 305-532-9675 drrcuello @almaatahc.com
Home Work Fax Email address
..Business Name: Alma - Ata Healthcare I I C. Position: Chief Medical Officer
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�� Address: 1225 Alton Road Miami Beach Florida 33139
No. Street City State Zip Code
Professional License(describe) Medical Doctor Expires: 01-31-2016 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: Yes❑or No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months:Yeslfor No n
o Are you a registered voter in Miami Beach: Yes ❑or No ❑
• (Please check one): I am now a resident of: North Beach❑South Beach n Middle Beach❑
• I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
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*
. ❑Beach Preservation Board 0 Loan Review Committee*
❑Beautification Committee ❑Mayor's Green Ad-Hoc Committee
❑Board of Adjustment* ❑Marine Authority*
o Budget Advisory Committee ❑Miami Beach Cultural Arts Council
❑Committee on Homeless 0 Miami Beach Commission on Status of Women
❑Committee for Quality Education in MB ❑Miami Beach Florida Sister Cities
❑Community Development Advisory* 0 Normandy Shores Local Gov't Neigh. Improvement
❑Community Relations Board ❑Oversight Committee for General Obligation Bond
❑Convention Center Advisory Board ❑Parks and Recreation Facilities Board
❑Debarment Committee 0 Personnel Board*
❑Design Review Board* fl Planning Board*
❑Disability Access Committee ❑Police Citizens Relations Committee
❑Fine Arts Board 0 Production Industry Council
❑Golf Advisory Committee 0 Public Safety Advisory Committee
10 Health Advisory Committee 0 Safety Committee
Zit Health Facilities Authority Board ❑Transportation and Parking Committee
❑Hispanic Affairs Committee 0 Visitor and Convention Authority*
❑Historic Preservation Board* ❑Youth Center Advisory Board
*Board Required to File State Disclosure form
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C:\Documents and Settings\compurbmlLocal Settings\Temporary Internet Files\OLK1C51BC 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 C No C Years of Service:
2. Present participation in Youth Center activities by your children Yes❑ No 0. 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:
a Have you ever been convicted of a felony:Yes❑or No❑ If yes, please explain in detail: .
• Do you currently have a violation(s)of City of Miami Beach codes:Yes C or No O. If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes Ei or No C. If yes, explain in detail
e Are you currently serving on any City Boards or Committees:Yes❑or No C. If yes;which board?
•What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties owned or have an interest in,which are located within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes❑or idol,. Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent 0,spouse❑, child❑,brother i 1,or sister n 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,
Art' . —of the City Code"Standards of Conduct for City Officers,Employees and Agency Members."
12-03-2016 Richard Cuello-Fuentes, M.D.
App icant's Signature Date 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 1/25107 jo
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C:1Documents and SettingslcompurbrnLocal Settings\Temporary Internet FileslOLK1C51BC Application Revised July 18 2007.doc
RICHARD CUELLO -EUENTES, M.D.
-1225-A•LTON RD._.-...
MIAMI BEACH, FLORIDA, 33139
TELEPHONE: (305)532-9926
FAX: (305)532-9675
WORK EXPERIENCE Alma-Ata Healthcare
1225 Alton Rd
Miami Beach, Florida, 33139
2010-Present
Hammocks Medical Offices
10201 Hammocks Boulevard Ste 123
Miami, Florida, 33196
2010-Present
Miami Beach Medical Group
Miami beach, Florida, 33139
2000-2010
HOSPITAL-5 Mount-Sin-al
AFILIATIONS University of Miami
POSTGRADUATE Internal Medicine Residenc
v
UMass Memorial Health Care
University of Massachusetts
Worcester, MA (July1997-2000)
Mini-Residency Program
Internal Medicine and Infectious Disease
Mount Sinai Medical Center
Miami, Florida (Oct-Nov 1996)
EDUCATION Autonomous University of Central America
San Jose, Costa Rica (1991-1995)
Degree: M.D.
Florida International University
Miami, Florida (1989-1991)
Degree: BA Chemistry
Miami Dade Community College
Miami, Florida (1986-1989)
Degree: AA in Liberal Sciences
LICENSURE Florida Medical License
CERTIFICATION Basic Life Support
Advanced Cardiac Life Support
ECFMG (valid indefinitely)
MEMBERSHIPS -American-College of.Physicians -
American-Society-of Internal Medicine
American Medical Association
PRESENTATIONS Dyslipidemias
Grand Rounds.
Presented at UMass Memorial Health Care
Worcester, MA (April 2000)
Prostate.Cancer Screening
Presented at UMass Memorial Health Care
Worcester, MA (April 1998)
Breast Cancer Screening
• Presented at;UMass Memorial Health Care
Worcester, MA (October 1998)
LANGUAGES English, Spanish and-French
PERSONAL Travel, reading theater, exercise and nutrition
INTERESTS
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