20161109 Release 3MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
COMMISSION MEMORANDUM
TO: Mayor Philip Levine and Members of the City Commission
FROM: Rafael E. Granado, City Clerk
DATE: November 8, 2016
SUBJECT: City Commission At -Large Nominations for November 9, 2016 — Release # 3
Below please find the City Commission At -Large Nominations received to date for the November
9, 2016 Commission Meeting. Item received since Release # 2 are shown in .
BOARD AND COMMITTEES
1. AFFORDABLE HOUSING ADVISORY COMMITTEE
VACANCY (1):
No nomination received do date.
2. ART IN PUBLIC PLACES COMMITTEE
VACANCY (1):
• Francinelee Hand (Release # 3, Page 3)
o Nominated for appointment by Commissioner Rosen Gonzalez.
o Nominated for appointment by Commissioner Grieco.
3. BUDGET ADVISORY COMMITTEE
VACANCY (1):
No nomination received to date.
4. BUDGET ADVISORY COMMITTEE
VACANCY (1):
No nomination received to date.
5. HEALTH FACILITIES AUTHORITY BOARD
VACANCIES (0):
POSSIBLE REAPPOINTMENTS TO BE MADE (2):
No nomination received to date
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6. DESIGN REVIEW BOARD
VACANCIES (0)
• Daniel Veitia (Release # 2, Page 3)
o Nominated for appointment, effective January 1, 2017, (At -Large position) by
Commissioner Grieco.
o Nominated for appointment, effective January 1, 2017, (At -Large position) by
Commissioner Aleman.
Clerk's Note: Ms. Carol Housen, who currently holds an At -Large position in the Design
Review Board, will be termed limited effective December 31, 2016.
7. HUMAN RIGHTS COMMITTEE
VACANCY (1):
• Jesse Fleet (Release # 1, Page 13)
o Nominated for appointment by Commissioner Grieco.
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Francinelee Hand
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^.11AMlBEACH
BOARD AND COMMITTEE APPLICATION FORM
Last N
Home Address
3
Home Telephone Work e phone
-30i Od7,37o
Business Name
First Name
Middle Initial
City 3 3f,./0State Zip Code
Cellular Telephorw Email address
Occupation
Business Address R / City State
Professional License (describe):8r11 MA Expires: 11,Af,(Q_L/
Please attach a copy of currently effective professional license.
Zip Code
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 -10i or No
• Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes Zi or No Ur
• Are you a registered voter in Miami Beach: Yes + or No
• I am now a resident of: North Beach South Beach ZI Middle Beach a
• I a s applying for an Appointment because I have special abilities,,knowledge and exp ie ce. le4se list below:
emv ?Yt E' (eft wt 04 t (J C irr .ti s4& 01 t a rrt l Cil Pq It f'—
Co A)" .Lt,' ,u 7((c� �l h� T sicoi,k, . 7J he 5� , 301&,,& Al6GA--
A( ce(la, f � �r i1 ski 11S" bovyk req at �' -kul� IPC r/
• Are you presently a registered lobbyist with the City of Miami Beach? Yes or No ar
CCS M i"j vsh -) �f� r (t' Q U KCS- C(4 1/
Please list your preferences in orde of ranking [1] t 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 Advisory Committee
0 Parks and Recreation Facilities Board °O
❑ Art in Public Places Committee
0 Health Facilities Authority Board
0 Personnel Board
❑ Audit Committee
0 Hispanic Affairs Committee
0 Planning Board**
❑ Board of Adjustment •*
0 Historic Preservation Board*
0 Police Citizens Relations Committee
❑ Budget Advisory Committee
0 Housing Authority
roduction Industry Council
❑ Committee on the Homeless
0 Human Rights Committee
f ister Cities Program
❑ Committee for Quality Education in MB
0 LGBT Advisory Committee
Sustainability Committee
❑ Convention Center Advisory Board
0 Marine & Waterfront Protection Authority
0 Transportation, Parking, & Bicycle -Pedestrian
Facilities Committee
4.uItural Arts Council
0 Miami Beach Commission for Women
Wisitor and Convention Authority
Design Review Board*
0 Normandy Shores Local Government
Neighborhood Improvement
0 Youth Commission
❑ Disability Access Committee
* 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 -effectively license, and furnish the
following information:
Type of Professional License License Number
License Issuance Date License Expiration Date
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oO 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
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 [1 or No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes or No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? Yes or No 1Z11 If yes, explain in detail:
• Are you currently serving on any City Board or Committee? Yes Elor No If yes, which board/committee?
COP .v1(SDr14v C4
• In what organization(s)"in the City of Miami Beach do you currently'hoolld�m�b rship? j
M � qea,- Gcl l L-Vl/ J' "> Gct, AI, tC/riy f (, !``K l � + , ► Jad kd o 1 c �y ii e
Name / Pdsition 7
Name Position
• List all properties owned or in which yo.y have an interest within the City of Miami Beach:
i Oi 4/ — / 3 I ''S No k ,r �2 ck
• Are you now employed by the City of Miami Beach? Yes ❑ or No Zr-
Which department and title?
• Pursuant to City Code Section 2-25 (b : Do you fhaveparent � spouse [::11, child brother or sister who is
employed by the City of Miami Beach? Yes LJor No �J
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 LJI
Race/Ethnic Categories
What is your race?
African-American/Black
� Caucasian/White
Asian or Pacific Islander
Native-American/American Indian
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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
Yes
Do you consider yourself Physically Disabled?
1_4No
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
STATU S ACCORDINGLY."
j licant'a ignature
Received in the Office of the City Clerk by:
Date
Name of Applicant (LEASE PRINT)
CL w O v L/2,6,4._
Nameof Deputy Clerk
�o Z, /6 /a/Z /‘
Control No. ate
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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MIAMBEACH
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: Fr n f .lithe,
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.
/ION% ,9
Signature
Updated: Tuesday, October 04, 2016
Date
Date
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