Loading...
Peter R. Martin Application Package MI/ \MI BEACH ® BOARD AND COMMITTEE APPLICATION FORM kAi\R—r1 EVE Cgo GER) Last Name First Name Middle Initial 60 3 EkSi bi Lr h o M B A + BIPtc--1-4 t S 9 Home Address City State Zip Code ;050. - 67 ' 120G e©e-60 (-)A14120 CNA" Home Telephone Work Telephone p p e Cellular Telephone Email address T(EPtTR E 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 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 or No L • Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes or No ►+71. • Are you a registered voter in Miami Beach: Yes M or No • I am now a resident of: North Beach South Beach Middle Beach Li • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: T 4 G l-1 6 b f C— S Gi Mjt If • Are you presently a registered lobbyist with the City of Miami Beach? 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 Office of the City Clerk. ❑Affordable Housing Advisory Committee 0 Health Facilities Authority Board ❑Normandy Shores Local Government Neighborhood Improvement ❑Art in Public Places Committee ❑Hispanic Affairs Committee 0 Parks and Recreation Facilities Board °O ❑Board of Adjustment** ❑Historic Preservation Board 'a ❑Personnel Board ❑Budget Advisory Committee ❑Housing Authority ❑Planning Board** ❑Committee on the Homeless ❑LGBT Advisory Committee ❑Police Citizens Relations Committee ❑Committee for Quality Education in MB ❑Marine&Waterfront Protection Authority ❑Production Industry Council ❑Convention Center Advisory Board ❑Miami Beach Commission for Women ❑Sustainability Committee ❑Design Review Board** /Miami Beach Cultural Arts Council ❑Transportation, Parking,&Bicycle-Pedestrian Facilities Committee _b Disability Access Committee ❑Miami Beach Human Rights Committee ❑Visitor and Convention Authority ❑Health Advisory Committee ❑Miami Beach Sister Cities Program * Board members are required to file Form 1 —"Statement of Financial Interest"with the State. *If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustment, Design Review Board, Historic Preservation Board or Planning Board, attach a copy of your currently-effective license, and furnish the following information: Type of Professional License License Number License Issuance Date License Expiration Date P-w ,i-}e I n? Page 1 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx °O 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 and/or 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 No 4-9 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 LD or No r If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach Code?Yes or No'=s. If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money?Yes I, 11 or No I I If yes, explain in detail: •Are you currently serving on any City Board or Committee?Yes or No Igt 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: 100&D ` •Are you now employed by the City of Miami Beach?Yes or No rk4 Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent I,_ .11, spouse Z11, child brother I, 11 or sister who is employed by the City of Miami Beach?Yes 1 -�or No If"Yes," identify person(s)and department(s): 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 Race/Ethnic Categories What is your race? African-American/Black Caucasian/White Asian or Pacific Islander 4i Native-American/American Indian Page 2 of 4 F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx • lZh Other—Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a. 0 No Z1 Yes Do you consider yourself Physically Disabled? A. No Zt 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." A41 "fr //61lr% 9/3//*' R iv/W-rt7 / AI pplicant's Signature Date Name of Applicant(PLEASE PRINT) Received in the Office of the City Clerk by: //r/r. Name of Deputy Clerk Control No. ate 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:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx i MIAMI BEACH City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK 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: 4t/- 04- d2 77 Ai 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 more than $500, 60 days in jail or both. AtiA,,, 6.4v. k: tig Signature Date Updated:Friday,June 05,2015 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx Peter R. (Roger) Martin 603 East Dilido Drive Miami Beach Fl 33139 305-674-1206 rog603 @yahoo.com Resume for appointment to the Miami Beach Cultural Arts Council Born and educated in New Zealand. American citizenship granted in 1966. Miami Beach resident 19 years. Miami/Dade resident 54 years. Fighter pilot Royal Canadian Air Force 1951-1957. Airline pilot 1957-1986. Retired as Captain from Eastern Airlines. Member of the Miami/Dade theatre community since 1989. Retired member of Actors' Equity Association, Screen Actors'Guild, and American Federation of Television and Radio Artists. Retired member of The Dramatists' Guild. Judge for the Carbonell Awards Committee 2000-2006. Co-producer and MC for Carbonell Awards Presentations. Former editor of miamiartzine.com. Current member of the American Theatre Critics'Association. f q - r -- Ili::-'2.' -4`• 1. t t. 6 J i,:'7;',1_,'",' , --' '''A11110 ',.'- T W 6 � 1u•. N i F nSr. 2 0414, -,-' -..,., P