Leslie Coller Application Package pending resume and photo , .
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M Y 1I 9 •
` -Q— BOARD AND COO ITTEE APP ATI0N FORM
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Last Name
first ame Middle Initial
3OI e y, ,FL
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Home Address City State 1, Zi Co e
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3C)5- CZ.CO 1 — 1 Ck C:)- - 9 r-i q -/ -7 loci tgs IQ ,CIDI ilk C-
None Cellular Home Telephone Work Tele
p e ular Telephone Email ad resei rY)0a. C,LY)')
Business Name Occupation
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 owners ip/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 ti or No Et
• Demonstrates ownership/interest in a business in Mi i Beach for a minimum of six months: Yes D or No
• Are you a registered voter in Miami Beach: Yes or No ij
• I am now a resident of: North Beach IZt South Beach IZI Middle Beach
• 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?
Y Y Yes 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 Charter Review and Revision Board ❑Disability Access Committee ❑Miami Beach Human Rights Committee
❑Ad Hoc Committee Centennial Celebration 0 Gay, Lesbian, Bisexual and Transgender 0 Miami Beach Sister Cities Program
Enhancement Committee(GLBT)
❑Affordable Housing Advisory Committee ❑Health Advisory Committee ❑Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee ❑Health Facilities Authority Board ❑Parks and Recreation Facilities Board
❑Board of Adjustment* * 0 Hispanic Affairs Committee 0 Personnel Board
❑B get Advisory Committee 0 Historic Preservation Board ❑Planning Board
❑ ommittee on the Homeless ❑Hou ing Authority ❑Police Citizens Relations Committee
Committee for Quality Education in MB ❑M fine&Waterfront Protection Authority 0 Production Industry Council
0 Convention Center Advisory Board iami Beach Commission for Women ❑Sustainability Committee
❑Design Review Board** ❑Miami Beach Cultural Arts Council. 0 Transportation, Parking,&Bicycle-Pedestrian
Facilities Committee
❑Visitor and Convention Authority
C) 1...0
* Board members are required to file Form 1 -"Statement of Financial Interest"with the State. --
If --
you seek appointment —I
y ppointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustm:ent, esign Review
Board, Historic Preservation Board or Planning Board, attach a copy of your currently-effectively license,:a d furnish the
following information: r -
Type of Professional License License Number
License Issuance Date v- : °
License Expiration Date r--..• ,
C W .
CZ)
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co 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 D Dates of Service:
2. Present participation in Youth Center activities by your children:Yes No Ti
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: Ase: Program:
• Have you ever been convicted of a felony?Yes IZI or Noa If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach Code?Yes Di or No If es please explain in detail.
yes, p p
• Do you currently owe the City of Miami Beach any money?Yes Ti or No In If yes, explain in detail:
• e you currently serving on any City o rd or C mmi ee?Yes I or No Ti If yes, which board/committee?
rr)4 \cn Ali bOoI1 0
• In what organization(s)in the City of Miami Beach do you currently hold membership?
Name Position
Name Position
• List al properties owned wr i which you e an inter st within t ,City f Miami Beach:
VIL\ CS-TIP Qao�,n2 v_.-- e_ct Cpl
7- 9
•Are you now employed by the City of Miami Beach?Yes or No
FW
Which department and title? .
• Pursuant to City Code Section 2-25 (b): Do you have a parent Ti, spouse Ti, child Ti brother Ti or sister Ti who is
employed by the City of Miami Beach?Check all that apply.
If"Yes,"identify person(s)and department(s):
I
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 omply with City diversity reporting requirements.
Gender: Male Ti Female •
1 N
Race/Ethnic Categories =W1
What is your race?
La African-American/Black :a.) -- 'r,
Ti Caucasian/White ;`
Asian or Pacific Islander ' �t-t
Ti
LO Native-American/American Indian ' '-i
:°7 ca)
Ti Other—Print Race: rri. p
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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.
La No
Yes
Do y'u consider yourself Physically Disabled?
It No
Z1 Yes
I 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
STATUTE ACCO`�IN.,
31011y
Lts ODPti
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A. ca 's Signature ate 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.
CD
rTji
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IV\ IAMI
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
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: 6)/(gf
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"
For your convenience, the form is attached. The form can also be downloaded at:
http://www.miamidade.gov/elections/Library/source of income statement.pdf
2. A "Statement of Financial Interests (Form 1)"
For your convenience, the form is attached. The form can also be downloaded at:
http://www.ethics.state.fl.us/ethics/forms.html
3. A Copy of your 2013 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.
if iff 4/ 0 jy,
Sig -ture Da e -
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Updated:Thursday, February 20,2014 r _}�e kap
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