Jared R. Plitt Application Package .. .
/\/\j/\1\/\t ; j
BOARD AND COMMITTEE APPLICATION FORM
1i;tt V;
Last Name Firs Na a id le Initial
4t3r a jgg fF, FL
Home Address City State Zip Code
1 .s' X34— 2nç 3.c or 7I S 4qrcnrn JqI *
Tele hoe
p Work Telep one Cellular Telep e . mail addre b
01 c Pj;v, on
si ess Name Occup ion
nIst Sr. 7o6. M.o. FL SI 14°
Business Address City y State Zip Code
Professional License(describe):F'. tjib3lpbIIiftbSt Expires:Please attach a co py of curren t 1 y f
ective 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'.� 4,-..
• Demonstrates ownership/interest in a business in Miami B: w� or a minimum of six months: Ye•Kit it .:r No La
• Are you a registered voter in Miami Beach: Yes La or No :43fi
• I am now a resident of: North Beach South Beach " Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
r •
• Are you presently a registered lobbyist with the City of Miami Beach?Yes or N,r
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 ❑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** 0 Historic Preservation Board 0 Personnel Board
udget Advisory Committee Housing Authority ❑Planning Board**
Committee on the Homeless GBT Advisory Committee ❑Police Citizens Relations Committee
❑Committee for Quality Education in MB ❑ arine&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
❑Disability Access Committee Miami Beach Human Rights Committee ❑Visitor and Convention Authority
❑Health Advisory Committee iami 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,ustment, sign Review
Board, Historic Preservation Board or Planning Board, attach a copy of your currently-effective license , alpj furn{ish the
following information: �- c—. `, i
Type of Professional License License Number o _ `'
. r ) -
License Issuance Date License Expiration Date: _ --v
--.=
Page 1 of 4 f 03
F:\CLER\$ALLIaFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx
I
°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 La 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:
L.T
• Have you ever been convicted of a felony?Yes or N,0A 1 If yes, please explain in detail:
Y currently violation(s) City Code? or a• y , please p
• Do you current) have a violation s of Cit of Miami Beach Code. Yes If' es lease ex lain in detail:
IImo�,, ,A
• Do you currently owe the City of Miami Beach any money?Yes�!or N•'` If yes, explain in detail:
• Are y c iently serving on any City Board or Committee?Ye-;0 )1 r No Za If yes,which board/committee?
•Is Crt• St
• 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:
%WWI 122027Viiir WM
•Are you now employed by the City of Miami Beach?Yes or N �e
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you i a parent 1, spouse Z1, child I. ..li brother or sister who is
employed by the City of Miami Beach?Yes L'or N V
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 II
Race/Ethnic Categories
What is your race?
IF;African-American/Black
III, Caucasian/White
bill Asian or Pacific Islander
lZt Native-American/American Indian
Page 2 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx
t:
1 Other—Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a.
.,
No
I. 11 Yes
Do you consider yourself Physically Disabled?
No
4a 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—Fprm 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
WI ABIDE ' ° CHAPTER 2, ARTICLE VII, OF THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR I'Cl ' OFFIC i MPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
S UTES /; •''a RDINGLY." tqf
10/10 r —Safe A pi i
nt's ig re Da Name of Applicant(PLEASE PRINT)
'-eceived in the Office of the City Clerk by: Io /Z r
Name of Deputy Clerk Control No. Da �e
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
s.
MIAMI tE
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:
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.
foñi(.ic .
Sign / Da
Updated: Friday,June 05,2015
Page4of4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06052015.docx