Faye Goldin Application Package pending photo and resume ;t ' ; F�-;, '\w ; I ,- , , * q,� 1 CITY OF MIAMI BEACH
BOARDS AND COMMITTEE APPLICATION FORM
NAME: GOLQ3I\) ray(%
Last(Name First Name �,(� Middle Initial
(,�R
HOME ADDRESS: S 1 ' CLOZ. 9' 116. r L `�-s `V
No. Street City State Zip Code
3oc- q4.6- 0b6 • �LST Q.Q+h e-t�,,cLL PHONE:
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 minif six months in a business established in the city.
• Resident of Miami Beach for a minimum of six(6) months: Yes Zr�'o No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes❑or No p/
• Are you a registered voter in Miami Beach: Yes Zr No ❑
• (Please check one): I am now a resident of: North Beach 0 South Beach ❑ Middle Beach ia/
• I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
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 Art in Public Places Committee ❑ Housing Authority*
0 Beach Preservation Board 0 Loan Review Committee*
❑Beautification Committee ❑Mayor's Green Ad-Hoc Committee
❑Board of Adjustment* ❑Marine Authority*
❑Budget Advisory Committee 0 Miami Beach Cultural Arts Council
0 Committee on Homeless 0 Miami Beach Commission on Status of Women
0 Committee for Quality Education in MB 4 Miami Beach Florida Sister Cities
❑Community Development Advisory* 0 Normandy Shores Local Gov't Neigh. Improvement
❑Community Relations Board 0 Oversight Committee for General Obligation Bond ,
0 Convention Center Advisory Board ❑ Parks and Recreation Facilities Board "` cn
❑Debarment Committee ❑ Personnel Board*
❑Design Review Board* 0 Planning Board* r` E
0 Disability Access Committee 0 Police Citizens Relations Committee
0 Fine Arts Board ❑ Production Industry Council u
,R.
0 Golf Advisory Committee 0 Public Safety Advisory Committee :
0 Health Advisory Committee 0 Safety Committee °•°
❑Health Facilities Authority Board ❑Transportation and Parking Committee — (am)
0 Hispanic Affairs Committee ❑Visitor and Convention Authority*
0 Historic Preservation Board* ❑Youth Center Advisory Board
*Board Required to File State Disclosure form
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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 L;No LI Years of Service:
2. Present participation in Youth Center activities by your children Yes[ No LI. 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:
•Have you ever been convicted of a felony:-.Yes❑ or No i/If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes 0 or No /If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes 0 or No/If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes /r No U. If yes; which board?
1`1
• What organizations in the City of Miami Beach do you currently hold membership in?
•
Name: Title:
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 0 or No["Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent Li, spouse I ;, child I, brother I.;, or sister+ I who is employed by the
City of Miami Beach?Check all that apply. Identify the department(s):
This section is"not required" but desired: Age: years old Gender: Male 0 Females'
Ethnic 9rigin (Check one)
White African-American/Black❑ Hispanic: 0 Asian or Pacific Islander❑American Indian or Alaskan Native❑
Employment Status: Employed 0 Retired❑ Home-maker 0 Other❑
"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."
13,6-44`- s�- � l
FRYb G
Applicant' ignature Date Name of Applicant(PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE:Applications will remain on file for a period of one(1)calendar year.
Receiv ed in City Clerk's Office b y � tv Date t
Name of Deputy Clerk
P Y -
Document Control Number(Assigned by the City Clerk's Office) Entered By raa.� Date / s
Revised 1/25/07 jo
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Other—Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the"No"box if not Spanish, Hispanic, Latino/a.
eNo
Yes
Do y., consider yourself Physically Disabled?
FA No
h 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 CCORDINGLY."
. �/.-
_ . ��� F AQ , a � �
/rte i
A.plican,s ignature I ate Name of App'icant(PLEASE PRINT)
Received in the Office of the City Clerk by:
Name of Deputy Clerk Control No. Date
RKcQrYr'\ I Z/g l IS
PLEASE //�� ® RESUME, PHOTOGRAPH AND A COPY OF ANY
f LEASE ATTACH A CURRENT Y1E��6V® 9
APPLICABLE PROFESSIONAL LICENSE.
ATTACH SHEETS,ACH ADDITIONAL SHEETS IF NECESSARY, TO PROVIDE REQUIRED
INFORMATION.
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AA1A/\AIEAcH E AC H
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK'S OFFICE CityCierk @miamibeachfl.gov
Telephone: 305.673.741 1 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: F11 0 Cot,17-r
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.
/6„„e 1,_ gei(c
Signature Dat
Updated:Monday,April 20,2015
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