Mark Weithorn Application Package Pending Photo and Resume CA t'v'\ I A1V\I AC H CTY OF IstrilAMi BEACH
BOARD AND COMMITTEE APPLICATION FORM
NAME: WL-%/7/1.,i ti /144.-ff.
Last Name First Name Middle Initial
HOME ADDRESS: ( 13o <7/t L—4 7c'1-- ?3/<i,
Apt No. House No./Street City State Zip Code
PHONE: 70 s ' 2'76Y-evc ) 3 -s a??? - a? ? 3 P r7I 1_ cj�
Home Work Fax Email address
Business Name: Position:
Address:_
No. Street City State Zip Code
Professional License(describe) Expires: 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-g4 No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months: Yes❑or No
•Are you a registered voter in Miami Beach:Yes ®'or No 0
• (Please circle one): I am now a resident of: Borth Beach2 South Beach 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?Yes❑or No EiV
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 Affordable Housing Advisory Committee ❑Housing Authority
0 Art in Public Places Committee 0 Loan Review Committee
0 Beautification Committee 0 Marine Authority
❑Board of Adjustment* 0 Miami Beach Commission for Women
0 Budget Advisory Committee 0 Miami Beach Cultural Arts Council
0 Capital Improvements Projects Oversight Committee 0 Miami Beach Sister Cities Program
❑Committee on the Homeless ❑Normandy Shores Local Government Neigh. Improvement
0 Committee for Quality Education in MB 0 Parks and Recreation Facilities Board
❑Community Development Advisory ❑Personnel Board
0 Community Relations Board 0 Planning Board*
0 Convention Center Advisory Board ❑Police Citizens Relations Committee
❑Debarment Committee ❑Production Industry Council
❑Design Review Board* 0 Public Safety Advisory Committee
❑Disability Access Committee 0 Safety Committee
0 Fine Arts Board 0 Single Family Residential Review Panel
0 Gay, Lesbian, Bisexual and Transgender(GLBT) ❑Sustainability Committee
❑Golf Advisory Committee ❑Transparency Reliability&Accountability Committee"TRAC"
0 Health Advisory Committee 0 Transportation and Parking Committee
0 Health Facilities Authority Board ❑Visitor and Convention Authority
0 Hispanic Affairs Committee 0 Waterfront Protection Committee
❑Historic Preservation Board 0 Youth Center Advisory Board
*Board Required to File State Disclosure Form
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❑No 0 Years of Service:
2. Present participation in Youth Center activities by your children YesD No D. 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: •
•
F;\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc
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•Have you ever been convicted of a , ny: Yes or Nof yes, please explain in aetail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes D or Nom-If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ❑or No iVIf yes, explain in detail
•Are you currently serving on any City Boards or Committees: Yes r No C. If yes; which board? ' P c
E
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: /Ws"-714 `gc 'ii p c'✓P. C,),,? Title: -- d` c=mss-Jr-C
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 NoR(Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent l (spouse❑, child❑, brother❑, or sister❑who is employed by the
City of Miami Beach?Check all that apply. Identify the department(s):
Dnepr' Lief 7h.,,,,.
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 federal equal opportunity reporting requirements.
Gender: 17'Male ❑ Female
Ethnic Origin: Check one only (1)
C-f'White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East.
❑ African-American/Black (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa.
❑Hispanic: All persons of Mexican,Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin,regardless of race.
❑Asian or Pacific Islander:All persons having origins in any of the original peoples of the Far East,Southeast Asia,the Indian Subcontinent,on
the Pacific Islands. This area includes,for example,China,India,Japan,Korea,the Philippine Islands and Somoa.
❑American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain
Cultural identification through tribal affiliation or community recognition.
Physically Challenged: Yes❑or NoEr
Employment Status: Employed V Retired ❑ Homemaker❑ Other❑
NOTE: If appointed,you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to,the following:
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 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).
(re: 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).
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 have received, read and will abide by Chapter 2,
Article VII-of the City Code"Standards of Conduct for City Officers, Employees and Agency Members."
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1--/G 1 7/-or-
Applicant's Signature Date Name of Applicant(PLEASE PRINT)
Please attachaicopyof=younresumeltoathis application
NOTE::Appii': onsiwll` :mai on file`fora:period'of onel1):calendar_year.
Received in the City Clerk's Office by: • r 1 Date:_/ /2010 Control No. Date: /2010
Name of Deputy Clerk F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC pplication.doc