Brett A. Harris Application package pending photo and resume N'Lt
Last Name First Name Middle Initial
Home Address City State Zip Code
4° I t---
Home Telephone Work Telephone Cellular Telephone Email address
ikLI
Business Name Occupation
am 4
BusEness Address City State Zip Code
Professional License(describe): Expires:
Pl-ca5c erl'ach a copy of,.-rurimptly effective prof ossictwi 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 ownershiprnterest 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)mops:Yes*dui or No Zt
o Demonstrates ownership/interest in a busine94imi Beach for a minimum of six months:Yes 52...‘r No 0
•Are you a registered voter in Miami Beach. es J or No
o I am now a resident of: North Beach South Beach El Middle Beach Eza
o I am applying for an appointment because I have special abilities,knowledge and experience. Please list below:
a Are you presently a registered lobbyist with the City of Miami Beach?Yes Ca 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.
0 M Hoe Committee Centennial Celebration 0 Heaith Advisory Committee
ti Parks and Recreation Facilities Board t'a
O Affordable Housing Advisory Committee 0 Heath Facpitles Ai.rtho Board 0 Personnel Board
0 Art in Public Places Committee 0 Hispanic Affain5 Committee 0 Penni •Board
0 Board of Adustment 0 Historic Preservation sqard_ * 0 Police Citizens Relations Committee
a ;ild iet AcMcorvCotiirnt 0 Housink Authorit 0 Production Indue Council
o Committee on the Hornet ess 0 Marino&Waterfront Protection Authorit Sustainaboit CornMittee
0 Committee for Quality Education in MB 0 Miami Beach Commission for Women 0 Transportation,Parking.&Bicycle-Pede,strion
Facilities Committee
0 Convention Center Advisor Board 0 Miami Beach Cultural Arts Council 0 Visitor and Convention Authosit-
0 Design Review Boar& * 0 Miami Beach Human Rights Committee
0 Disabitit Access Committee 0 Miami Beach Sister Cities I;! ram
0 Gay,Lesbian,Bisexual and Transgender Mormandy Shores Local Government
h 1111
Enancement Committee GLBT ili•hborhood Irn•rovement
* Board members are required to file Form I—"Statement of Financial Interest"with the State.
*If you seek appointment to a professional seat(e.g., lawyer, architect.,etc 4 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 of 4 001
FACLER,SALLV-LFORPASIWARD AND COMMITTEESISC APPLACATION REVISED 0602/014Acx
• 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 andtor 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 _DI No
If yes.please list below the names of your children,their ages and the programs in which they participate:
Child's name: Age: _ Pmgrarn:
Child's name: Program:
•Have you ever been convicted of a felony?Yes ED or No'Grit'yes,please explain in detail:
•Do you currently have a violation(s)of City of Miami Beach Code?Yes La or N.IIMJ If es,please explain in detail:
•Do you currently owe the City of Miami Beach any money?Yes No If yes,explain in detail:
•Are you currently serving on any City Board or Committee?Yes Or No It yes,which board/committee?
0 In what organization(s)in the City of Miami Beach do you cuirently hold membership?
Name Position
Name Position
a List all properties owned or in which you have an interest within tha_City of Miami Beach:
. .
•
•Are you now employed by the City of Miami Beach?Yes or No'n
Which department and title?
• Pursuant to City Code Section 2-25(b): Do you have 445`arent I-22. spouse child brother or sister[=.3=who is
employed by the City of Miami Beach?Yes
If"Yes,"identify persch(s)and department(s):
The following informatio• •voluntary and is neither part of your application nor has any bearing on your consideration for
appointment It is bei a asked to comply with City diversity reporting requirements.
Gender: Male-11-ri: Female Or
Race/Ethnic Categories
What is r race?
Tican-Arnefican,(131ack
Caucasian/While
Asian Or Pacific Islander
C.3 Native-American/American Indian
Other—Print Race:
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F:Tt..EmsoiLlooFoRtassoARo AM>COMMITTEESSC APPLICATMI REVISIEb Cet.t2314.docx •
....
Do you consider yourself to be Spanish,Hispanic or Latino/a?Mork the"No"box if not Spanish,Hispanic,Latina/a
Yes
Do you co der yourself Physically Disabled?
No
O1 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).
a Prohibition from contracting with the City(Miami-Dada 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 CMS 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 Chanter ?6 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 those 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 A; A BY CHAPTER 2, ARTICLE VII, OF THE MIAMI BEACH CITY CODE., ENTITLED"STANDARDS OF CONDUCT FOR
Cu' •FFI*ERS,EMPLO EES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
'TATUT. ACCORDING' Y,"
• VIM -4):41
Alspoicarrt`s Slgr'ture bate Nine of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by:
Name of Deputy Clerk Contra 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 tCLEs SALLlaFORMStSOARD ANtb Cb-Mr4:fTEMOC APPLICATION REVISED Q6022C14.tla,
t 1 a: tC ':.1
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
CITY CLERK'S OFFICE CityClerk@miamibeachlI.gov
Telephone: 305.673.741 1 Fax: 305.673.7254
Acknowledgement of fines/suspension for BoardlCommittee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i)(2)
fi
Board Member's Name: ■—\
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 a- $500,60 days in jail or both.
Signature Da e
Updated:Tuosclay,January 06,2015
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F:`CLERIALL'.aFORMSIBOARD AND COWAITTEcy`,BC APPLrCATJON REVISED 06022014 dot',