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Carol A. Housen Application Package11AMI REACH ., .. v O€`v`MM T . EE APPLICAT!ON FORM Last Name First Name ea. Home Address City Home Telephone 20 1 Work Telephone e i 6 (' AD Z/ Business Name Bess Address ` Professional License (describe): / e9-5—, 'l 067 t Lsi2 Please attach a copy of currently effective professional l/cense. Middle Initial /2a� Cellular Telephone State Occupation City Al /V Zip Code l s / Email address State es: dr/4,rte 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 M or No • Demonstrates ownership/interest in a business in Miami Beach or a minimum of six months: Yes I_ I or No _ • Are you a registered voter in Miami Beach: Yes or No rch • 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: i2 ' .A .e v o • Are you presently a registered lobbyist with the City of Miami Beach? Yes __._i 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 Advisory Committee ❑ Parks and Recreation Facilities Board °o ❑ Art in Public Places Committee E. Health Facilities Authority Board ❑ Personnel Board 0 Audit Committee 00 Hispanic Affairs Committee Planning Board** ❑ Board of Adjustment ** 0 Historic Preservation Board' XPolice Citizens Relations Committee�J 0 Budget Advisory Committee 0 Housing Authority 0 Production Industry Council Committee on the Homeless 0 Human Rights Committee 9 Sister Cities Program ❑ Committee for Quality Education in MB _, LGBT Advisory Committee 0 Sustainability Committee 9 Convention Center Advisory Board 0 Marine & Waterfront Protection Authority 0 Transportation, Parking, & Bicycle -Pedestrian Facilities Committee ❑ Cultural Arts Council ❑ Miami Beach Commission for Women 0 Visitor and Convention Authority ❑ Design Review Board Normandy Shores Local Government _a eighborhood 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 Lt _ nse Number 1 n 5 9 6(,' License Issuance Date F / 7 7 3 License Expiration Date Page 1 of 4 F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx °° 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: Child's name: Age: t Program: Program: • Have you ever been convicted of a felony? Yes Zi or No ffiZI If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach Code? Yes or Nof yes, please explain in detail: • Do you currently owe the City of Miami Beach any money? Yes Fij or No' 'J If yes, explain in detail: • Are you currently serving on any City Board or Committee? Yes or No If yes, which board/committee? C.!?n rrr1 • In what organiz_ 'on(s) in the Cityof Miami Beach do you currently membership? t, 4� . G ( S -C7 I c s le ,-) 7�' Name eh 6?4, J Positi ,�y� Name !/! Position ��r� • List all roperties own or in which you have an interest within the City of Miami Beach: -eoo (1 /2?' , --?�i,// ` 005- -to5r' doi = . l % � 0/..s" 6 7 s7 * /// 7 =3 / 4/ / • Are you now employed by the City of Miami Beach? Yes or N Which department and title? • Pursuant to City Code Section 2-25 (b):IDo you hav a parent , spouse child D brother or sister who is employed by the City of Miami Beach? Yes 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 omply with City diversity reporting requirements. Gender: Male LJ Female Race/Ethnic Categories What is your race? Zi African-American/Black Caucasian/White Asian or Pacific Islander Native-American/American Indian Page 2 of 4 F:\CLER\SALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx D 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? No 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: c 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." Applicant's Signature Date / Name of Applicant (PLEASE PRINT) Received in the Office of the City Clerk by: QLA-Q,zpti-o - id/406" Name of Deputy Clerk Control No. Date 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 06142016.docx t I L 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 d S E4) 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 Tater 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. Signature Updated: Tuesday, October 04, 2016 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx /0// //i& Date STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CQ1044839 ISSUED: 09/18/2014 REAL ESTATE CORPORATION MAGIC CITY REALTORS LLC HAS REGISTERED under the provisions 1 of h-4755FS. Expiration date : SEP 30, 2016 CAROL HOUSEN BROKER, CIPS, CRS. GRI Master Broker Forum MAGIC CITY REALTORS 90 Almeria Avenue Coral Gables, Florida 33134 Facebook: Magiccityrealtors www.carolhousen.com carolhousen@gmail.com 305.992-8163 cal#oma p c.Ips,013:s,,Ci goo& Owe 4ac; RSP1 Knowledge, Experience, Service and Integrity Profiles of Success and Education and Affiliations since 1993 • Member of Master Brokers Forum (A distinguished network of realtor professionals recognized as leaders in the industry • G.R.I. (Graduate Realtor Institute) • C.R.S. (Certified Residential Specialist- est. 4% Nationally) • C.I.P.S. (Certified International Property Specialist -specific education to work with foreign nationals) • Former Chair of Grievance with the Realtor association Miami RE • Present serving on Arbitration with Realtor association Miami RE • Mediation trained and serving Realtor Association of Miami -present • Served on Board of Directors of Realtor Association of Miami and the Beaches (Miami RE) from 1999 until 2008 (local) • Current Affiliation: Ombudsman Miami Association of Realtors • Director with Florida Association of Realtors( FAR )(State) President of one Condominium Board in Miami Beach • President of North Beach Development Corporation (non for profit -501 C3) • Hosting monthly police meetings in north beach • Contact for Ocean Terrace HOA Crime waitch Treasurer of Teen Job Corp • Former Chair of the Fine Arts Board for City of Miami Beach 2009 and 2010 • Chairman of Miami Beach Design Review Board • Served since 2011 on DRB until present as Chair for last 2 years • Active with Realtor Political Action Committee as a major investor. RPAC • Miami Beach resident since 2001 • Member of Miami Beach Chamber • Awarded —Honor Society —Board of Realtors • City of Miami Beach 2014- Proclamation for work done in NOBE 7330 Ocean Terrace Unit 2001 Miami Beach , FI 33141 3059928163 carolhousen@gmail.com