Jill Shockett Application PackageMLA.MI BEACH
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Home Addr_
Home Telephone
Work Telephone
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Business Name
BOARD AND COMMITTEE APPLICATION FORM
First Name
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City State
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Cellular Telephone
Occupation
Middle Initial
Zip Code
Email address
Business Address
City
State
Zip Code
Professional License (describe): Expires:
Please attach a copy of currently effective 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 dernonstrate ownership/interest for a minimum of six morths 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 Efor No l
• Demonstrates ownership/interest in a business in mi Beach for a minimum of six months: Yes J' or No
• Are you a registered voter in Miami Beac .• Yes or No Zi
• I am now a resident of: North Beach IA South Beach Zi Middle Beach
• I am applying f r an appointment bec hay special abilities, knowledge and experience. Please list below:
7have,
ao a(i I/a,f .'r1/,' (�� / iv1420���e �'I . �lev'e&1 �i °Ile 4 ,af m
• A you presently a registered lobbyist with the City of Miami Beach? Yes �or No 1
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
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
0 Production Industry Council
❑ Committee on the Homeless
0 Human Rights Committee
0 Sister Cities Program
❑ Committee for Quality Education in MB
0 LGBT Advisory Committee
0 Marine & Waterfront Protection Authority
0 Sustainability Committee
0 Transportation, Parking, & Bicycle -Pedestrian
Facilities Committee
❑ Convention Center Advisory Board
❑ Cultural Arts Council
/
l�Miami Beach Commission for Women 2
'Visitor and Convention Authority Z.1"1 -161p
171 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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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 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 Zi or No '/1 If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes or No0 If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? Yes or No IA If yes, explain in detail:
• Are you currently serving on any City Board or Committee? Yes
or No If yes, which board/committee?
• Inw t organization(s) in the City of Miami Beach do you curre hold membership?
Name (Yma`/ Position
Name Position
• List all properties own or in whi ouhave an interest within the City of Miami Beach:
• Are you now employed by the City of Miami Beach? Yes rj or No
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you lav a parent U, spouse child brother F,D or sister Zi who is
employed by the City of Miami Beach? Yes Uor No I Add
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 Ul Female!
Race/Ethnic Categories
What is your race?
4 African-American/Black
Caucasian/White
FZI Asian or Pacific Islander
Native-American/American Indian
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Other— Print Race:
D` o you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a.
1 No
Yes
u 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:
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
STAT TES ACCORDINGLY."
App ant' Si. atur
Received in the Office of the City Clerk by:
41a4 g') 26/ OekeiZ41,
Date Name of Applicant (PL SE PRINT)
14,e-) 4 6Qi ZGt, cl e- /10/Z6 6 -
Name
Name of Deputy Clerk Control No.
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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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