Dawn McCall Application Form a.
MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM
M DpitaSt4 L.
Last Name First Name Middle Initial
luau S. Ebitvlc. 17R. 'tc.2101 JVI Bm.c.1-. F L- 3313 9
Home Address City State Zip Code
3017°4-37(01
Home Telephone 1 Work Telephone 1" Cellular Telephone C Email address
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Business Name Occupation Bec.,110 tr.�cs�+i SSA AV c- AA r2 3 313
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 ID or No
• Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months:Yes CD or No
•Are you a registered voter in Miami Beach:Yes al or No
• I am now a resident of North Beach South Beach Middle Beach EJ
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
•Are you presently a registered lobbyist with the City of Miami Beach?Yes Zi or No
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that
on! three 3 choices will be observed b the C' Clerk's Office.
Affordable Housing Advisory Committee Fine Arts Board Normandy Shores Local Government\
Neighborhood Improvement
Art in Public Places Committee Disability Access Committee Parks and Recreation Facilities Board
Beautification Committee Gay,Lesbian,Bisexual and Transgender Personnel Board
Enhancement Committee(GLBT)
Bicycle-Pedestrian Advisory Committee Golf Advisory Committee Planning Board
Board of Adjustment* * Health Advisory Committee Police Citizens Relations Committee
Budget Advisory Committee Health Facilities Authority Board Production Industry Council 3
Capital Improvements Projects Hispanic Affairs Committee Safety Committee
Oversight Committee
Committee on the Homeless Historic Preservation Board t Single Family Residential Review Panel
Committee for Quality Education in MB Housing Authority Sustainability Committee
Community Development Advisory Loan Review Committee Tennis Advisory Committee
Community Relations Board Marine Authority Transportation and Parking Committee
Convention Center Advisory Board Miami Beach Commission for Women Visitor and Convention Authority Z
Debarment Committee Miami Beach Cultural Arts Council Youth Center Advisory Board °o
Design Review Board** Miami Beach Human Rights Committee Waterfront Protection Committee
Miami Beach Sister Cities Program S. Pea itbe Cob..vv tc CepriewvQi Ce140 :'1 1..
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0O Note:If applying for Youth Center Advisory Board,please indicate your affiliation with the Scott Rakow Youth Center.
1.Past service on the Youth Center Advisory.Board:Yes❑No❑ Dates of Service:
2.Present participation in Youth Center activities by your children:Yes❑ No❑
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 al If yes,please explain in detail:
•Do you currently have a violation(s)of City of Miami Beach Code?Yes❑or Nola!'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 Board or Committee?Yes❑or No❑If yes,which board/committee?
•In what organization(s)in the City of Miami Beach do you currently hold membership?
Name Position
Name Position
•List all properties owned or in which you have an interest within the City of Miami Beach:
%1C 1.341 i CONZA irN1C
•Are you now employed by the City of Miami Beach?Yes❑or No❑
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ❑, spouse child III brother❑ or sister ❑who is
employed by the City of Miami Beach?Check all that apply.
If"Yes,"identify person(s)and department(s): No
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 al
Race/Ethnic Categories
What is your race?
❑African-American/Black
❑CaucasianNVhite
❑Asian or Pacific Islander
❑Native-American/American Indian
❑Other—Print Race:
• Page 2 of 4
• •
Do you consider yourself to be Spanish,Hispanic or Latino/a?Mark the"No"box if not Spanish, Hispanic, Latino/a.
No
Yes
Do you consider yourself Physically Disabled?
Ill No
1:11 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."
44eri 4440 /6-31-13 17it-41 L. cCq-LL.
Applicant's Signature Date Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date
PLEASE REMEMBER TO 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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