Deborah Joy Robins Application pending photo and resume 12/07!2015 21:23 305673725d CITYCLERK PAGE 61
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BOARD AND COMMITTEE APFUCATIOM FORM
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Lest Name �..�. First Name Miele I tl
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Home Address City State Zio Code
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tiome Telephone Work Telephone CellularTatephore Email adfreae
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usinne aadroae 1� S City i e sip Gods
Professional License rxteacribo}: � 2 r '
'' Expires: J 01. I 4 7
Please oUoch a;coy of currently offectJve prafenafonaf license.
Pursuant to City Code section 3-22(4)a a b:Members of agencies,boards and committees shall be affitlated with the
City.This requirement shall be fulfilled In the following ways: a. An Individual shall have been a resident of the City far 1
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.
a Resident of Miami Beach fora minimum of six(8)months:Yea tto /
e Demonstrates ownership/interest In a business in M Beach for a rnlnimum of six months:Yes,,_.�or No 0
a are you a re Ietered voter In Miami Baiter Yew ., or Nay
4
ra I am now a resident of Norte Beach ca Routh Beech Middle Beech -
a I am applying for an r.poirltrnen1 because 1 have special abilities.knowledge and ex.erlence. Please Het below:
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I -f-___. t-_1!)...- ..r.i.sizszLe__,_%/- ••.' et,r te•-____4.. ...s.....bAci-fit5,..,i, '.:.f2 IMIEMIr . 57 ..-".. I
Le Are you presently a registered lobbyist with the City of Miami Beach?Yes Ca or No 1
.
Please list your preferences in order of ranking(1] first memo choice(2)second choke, and(3) third choice. P. o note that '
0Aflordabla Housing Advisory Committee 0 Health Fadilties Authority Board 0 NMfnsdy►slievel Lail GOWIIMS11 ,j
Nol.ohbofiac�d Im rrt�n1 rl i
CI Art to Publie Plata Cais nties 3 Hispanic Affairs Camm!eae 0 Pints snp ReciaStOr Feades SMOrm°o
C saes of AO, giant' .. ^p Hle_torio P ref ..„ IParsonr erd_
i 9udtlat Advil orp CoinMttae _, r_r ttovi •Author/ anrtlnS 3rtosrtf' _
r on The Momeleas ems' 0 LG2T Advffi.. .atrnittes a 0 Police ci,.one Rotation Car thse
Committee for Cua y gdycarri 'n file o Manisa&Waterfront Protection AulhorltY,,..,... 0 Production trx�str!Council
C1,Convertlorr Cent+oeAdvise 6oart 0 Mlsrnt Beach Commission for Woman L Z 1 C floltalisobility Commit s&
G Oe Sign tiovtegw Board' 0 loam Beach Cul Mral Al s Courts c Transco/le der.Peratng.&Siclicb•P'edeoM®n
FaetlLeo Cerr n'ZIao -
l ieobi' A _t_.Crone:rhos ' Mimi 9aachturren Rit�ttt'!Comrntttaea = o Vase?aria Cmeriiion Authority r
it Pooim Aavy rrbstae ;Beach Sister Cities Pro rarrt
ierd members are required to file Pore 1-"Statement of Financial Interest"with the Std.
*It you seek appointment to a professional seat(e.g.,lawyer, architect,etc.)on the Booed of Adjs tment,Cosign Pablaw { •
Board, Historic Preservation 9oard or Planning Opera ettlee'a copy of your currently-ef;e tivo license, and furnish the
following Infornmatiorr. -- a •
Type of Prcfessionel Lleafea License Numbee , _ err `,_.,
Uiesnve 5.upirattian Dotes ` '
wicende ld�eea flea , - � -�-
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Page 1 of a r„,-, —CD --
F:CLEFIAALIMPORMISODAPIO AND CQltaMrTi'£EStOC A P VIEWED Deoelei&.il cr
lid 171.91.-t7L9-90£ suigo l elgge0 860:l.i.91.80 080
12/07/2 @15 21:23 3656737254 CITYCLERK PAGE e2
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t o Note:I f applying for the Youth Center poaiplone of the Perna and Recreations Facllttioa?cord, ease indicate your of iiaticn with
Rolm Scott Ral Youth Center and0or the North Share Price Youth Center.o �� --
Please desorlbo your past eewion with the City's Youth Cantata(lnotudc Mateo of aor'toa): A-7 A— _,
o Present pertidpeiton in Youth Costar eo shine by your children:Yea s No ,,,-//r---
if yes,please Met below the names of your ohihfren,their ages and lite programa in which they partici;ete:
Child's Warne: _ _ Age: Program: _�__•__--_._. •
Gee's name: Age: tograrn: _
•HOW OM OYOM been Convicted of a fa!::ny'Yea ar Np If yea,please pleln In data
•Do you,currently have m viola on( )of City of Miami Beads Cade?Yes V or N 11 yes.pieties explain in detail:
o Da you currently owe the City of Miami Boat any money?Yea LI or No C }i ye®,explain In detail!
•Are you current/serving on any City Board or Committee?Yea aP Ms:LI If yea,which boardloomrnittee'P ,
a In vyt'1iiI or jenizetlor(a)In the City of Mimi Beech do you o'ently hold mernberahlp?
Name Position
Name Poaldan
.Llat all weenies owned or In which have kter®a NA t City of Wand De ;
44 on a Are you now employed by the City o f Mini Beech?Yam 1. or Ng
Which depsrbnent and title? _ _.... ---- .. _
a Pursutat to City Cooke Section 245(b: Do you have a parent , Tell a ter ar Later 0 who le
i ?.YCO No 4d
employed by the City of Miami beech A_f
it`Yes.'identify person(s)and dapwtrrleot(e):
The following Info4vnalion is voluntary end Is neither part of your application nor has any bearing on your cortsidereBon for
appointment It la being asked to own:, City diversity reporting requirements.--- --
Gender; Male III. fernsim I'
N elle Gete®srlee
What is your race?
o JAr riasvtJ@ieCk
uaaaienAWNta
La Aston or Pacific Islamist'
I C-13 Native knottcerVAmertCC1n Indian
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CeCt-igIMAUMFORMSISDARD AND COMM1111111319C APP CAIN 3N REVISED 40062Oi6.abox
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12/07/2015 21:23 3056737254 C I TYCLERK PAGE 03
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Other-Point Raw .
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Do you consider yourself to be;banish,Hispanic or Latino/a?Mark rh®"ND'box If not Spanish.Hispanic. Latinate.
LI Yes •
j Dm you confider yourself Physically Disabled,
twaslYBB
I
I NOTE.tF APPOINTED,YOU WILL ISE REQUIRED TO FOLLOW CERTAIN L.AWI THAT APPLY TO CITY BOARD COMMITTEE
MEMBERS.THESE LAWS INCLUDE,BIJT ARE NOT LIMITED TO:
o Prohibition from directly or Indirectly lobbying City personnel(Miami Beach City Cods section 2-459J.
1 o Prohibition from contracting with the City ildilemi•Dade County Code section 2.11.11,
o Prohibition from lobbying before the boerdreommittes you have served or for perioM of one year after leaving office fMierni Beech ;
(:It y Code seCtlon 2-262.
Requirement to di otose certain financial Interests end gifts Ilatri•Dede County Coda section 2.11.1).
c CMS Community Development Advisory Committee!prohibition,during tenure end for one year altar leaving office,from having
ar.y interest In or receiving any benefit from Community Development Block Grant funds for either yourself,or those with whom
your have usInos6 or immediate family lies(CFft 870.611), ,
ri 51.4nshins Law- Florida's Government-,n-the-Sunst Ine Law was enacted in 1967. Today, tFte Sunshine Lew regarding open , ••
government Can On found in Chapter 2n of the Fiorida Statutes. These statutes establish a basic right of stt:cess to most
meetings of boards.commissions and other governing bodies pf state and local governmental agencies or autiarities.
a Voting conflict w Form BB is for use by any person serving at the county.city or other local level of government on an appointee cr •
Coded board,council,commission, authority or committee.It applies equally to members of advisory and non-advisory bodice
who ere presented with a voting conflict of interest under Section 112.3143,Florida Statutes,
Upon request,copies of these Iowa may be obtained from the City Clerk.
I H BY ATTEST TO THE CURACY AND TRUTHFULNESS OF THE APPLICATION AND I HAVE RECEIVED,READ AND
LL ABIDE Y CHAPTER , RTICLE VII,OF THE ;VIM( BEACH CITY CODE,ENTITLED""STANDARDS OF CONDUCT FOR
C PFiC S,EMPLOYEES ND AGENCY MEMBERS AND ALL OTHER APFUCASLE COuNrr ANDIOR STATE LAWS AND
8TA TES C `D1NOLY. ,
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_i_________Applicant's Signature Den Nacre of Applicant(PLEASE PRINT) .
Rooekved albs in the Office City Clerk.by:
Nam of Deputy Clark Control 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. •
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F:IciaRtsALLiefORMIAB0ARe AND GQii ImTTEEeeCAPPLICATION REV VE0 M5201e.oac
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12:07/2015 21:23 3056 37254 CITYCLERK PACE 04
MIAMI BEACH
City of Miami®eoth
700 Convention Center Drive,
Miorni Beach, Flo►rdo 33!39,
wvw_miami beathf.gov
CITY CLERCS OFFICE CityClerk@rr.!omibeachfl.gov
Telephone: 305.673.741 1 Fox; 305.473,7234
Acknowledgement of flneslsuspension for BoardPCommIttee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2e11.1(I)(2)
O■ -- P-aE 1
Board Member's Name: r `S
I understand that no later than July 1, of ugly= 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 fife, even
though they may have been runty appointed,
,e of the following forms anlal,with the City Clerk of Miami Beach, 1700 Convention Center Crive,
Miami Beach, Florida, no pater than 12:00 noon of July 1,of each year.
1. A'Source of Income Statement"
2. A'Statement of Financial Interests(Form.i)"
3. A Copy of your latest Federal Income Tax Return
Failure to U one o't hese forms, pursuant to the Miami-Dade County Code, may subject the perscr to a fine
of no ma - = •C,r 60 days in jail or both.
AIL
7 rl
Signature Date
Uxxatei:i kmda r,April 2ij.2D1 S
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F:!CtERlSALL1AFOiiMS+r OARD AND COMMIrecut:APPL.'CATfON REVISED 17110220 4.ciao
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