Lori E. Gold Application PackageA1/VW BEACH
BOARD AND COMMITTEE APPLICATION FORM
Last Name
GJJ
O I C►
First Name Middle Initial
L�1Zt
Home Address
3 Is(aA'1 i
Home Telephone
Work Telephone
Business Name
City State Zip Code
Cellular Telephone Email ad r ss
Occupation
Business Address
Professional License (describe):
City
State
Expires:
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 Lor No
• Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes or No
• Are you a registered voter in Miami Beach: Yes aor No ZI
• I am now a resident of: North Beach Zi South Beach Middle Beach Zi
• I am applying for an appointment because I have special abilities, kno edge and experience. Please list below:
YY‘ =on on e nt \ 1f x c V eArkim vne x a. P -kr) CC c --V 1 e -i u`i
• Are you presently a registered lobbyist with the City of Miami Beach? Yes 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
0 Parks and Recreation Facilities Board
LNArt in Public Places Committee 3
0 Health Facilities Authority Board
Irsonnel Board
0 Audit Committee
0 Hispanic Affairs Committee
0 Planning Board**
0 Board of Adjustment *'j
0 Historic Preservation Board{
0 Police Citizens Relations Committee
0 Budget Advisory Committee
0 Housing Authority
0 Production Industry Council
VCommittee on the Homeless ,2.
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
0 Cultural Arts Council
0 Miami Beach Commission for Women
0 Visitor and Convention Authority
0 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 Professional License License Number
of
License Issuance Date License Expiration Date
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°° 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:
• Have you ever been convicted of a felony? Yes or No
Program:
Program:
4-1-f yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes or No4 If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? Yes or No W if yes, explain in detail:
• Are you currently serving on any City Board or Committee? Yes or No If yes, which board/committee? re/ Yl %
• In whit organization(s) in the City of Miami Beach do you currently hold membership?
Positicn
Na it actin -t % (d c? teiA t.4.O(
Name ( Position
• List all properties owned or i which you have an interest within the City of Miami Beach:
r �( /e i dtiL(i�' �GJ -hitt
t
• Are you now employed by the City of Miami Beach? Yes or No
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you have a parent La, spouse L:1, child brother La or sister La who is
employed by the City of Miami Beach? Yes L.—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 comply with City diversity reporting requirements.
Gender: Male I=J Female Lir
Race/Ethnic Categories
What is your race?
African-American/Black
larCaucasian/White
Asian or Pacific Islander
Native-American/American Indian
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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.
JNo
A Yes
Do you consider yourself Physically Disabled?
v(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.
ATION;
D I HAVE RECEIVED, READ AND
I BATTEST TO THE ACCURACY ER 2,ARTICLE VI, OF ND THE MIAMINESS BEA HFTHE C TY CODECENTIITLEDN "STANDARDS OF CONDUCT FOR
WILL ABIDE BY CHAPTER PT
CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
STATUTES, CCORDINGLYf"
Ap • • . nt' ignature
0-0,(YL
Received in the Office of the City Clerk by:
It o//' Logi
D to Name of Applicant (PLEASE PRINT)
LeaWi.„0Yl Qae' 4— 111576
Name of Deputy Clerk Control No.
///fi g
Date
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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t\AIAMI BEACH
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
CityClerk@miamibeachfl.gov
Telephone: 305.673.741 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)
L
-f
Board Member's Name: O . d
U J
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.
Si
tur
//-fryld
Updated: Tuesday, October 04, 2016
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I1//o//�
Date
LORI GOLD, J.D., M.S.
3 ISLAND AVENUE, PH -H
MIAMI BEACH, FL 33139
Mobile: (786) 390-7444
ttlorigold@aol.com
EDUCATION:
B.A., 1963, QUEENS COLLEGE, UNIV. OF CITY OF N.Y.
M.S. IN EDUCATION, 1965, CITY COLLEGE, UNIV. OF CITY OF N.Y.
J.D., 1983, EMORY UNIVERSITY, ATLANTA, GA.
PROFESSIONAL WORK EXPERIENCE
SCHOOL PSYCHOMETRIST, DIRECTOR OF ELEMENTARY SCHOOL
GUIDANCE PROGRAM, TEACHER
ATTORNEY, RETIRED MEMBER OF THE GEORGIA BAR
EXECUTIVE DIRECTOR GEORGIA PROFESSIONAL LICENSING BOARDS
DIVORCE MEDIATOR & TRAINER OF MEDIATORS
RECOGNITION & HONORS
2006 MIAMI BEACH KIWANIAN OF THE YEAR
1981 WHO'S WHO IN AMERICAN WOMEN
1980 LEADERSHIP ATLANTA
COMMUNITY LEADERSHIP ACTIVITIES (FLORIDA 1996 -PRESENT)
2006-2016 EESAC COMMITTEE, TREASURE ISLAND ELEMENTARY SCHOOL
2006-2016 PRESIDENT, BOARD MEMBER, FAMILY COUNSELING
SERVICES OF GREATER MIAMI & THE JOURNEY INSTITUTE &
SWITCHBOARD MIAMI
2016 FUNDING ARTS NETWORK
2012-2013 MIAMI BEACH CITIZENS POLICE ACADEMY
2007-2008 COMMITTEE FOR QUALITY EDUCATION IN MIAMI BEACH
2005-2006 MIAMI BEACH NEIGHBORHOOD LEADERSHIP ACADEMY ,
SECRETARY OF ALUMNI ASSOCIATION
2000-2007 KIWANIS CLUB OF MIAMI BEACH
1999-2004 TERRACE TOWERS CO-OP BOARD MEMBER; VICE PRESIDENT;
CHAIR OF BYLAWS REVISION AND LEGAL MATTERS COMMITTEES
COMMUNITY LEADERSHIP ACTIVITIES (GEORGIA 1969-1996)
PUBLIC ACCESS TELEVISION, PRESIDENT
55 PHARR ROAD CONDOMINIUM ASSOCIATION, PRESIDENT (6 YEARS)
AND MEMBER OF THAT BOARD FOR 8 YEARS
BRANDEIS WOMENS COMMITTEE, CHAIR OF COMMITTEES
ARTS FESTIVAL OF ATLANTA, CHAIR OF COMMITTEES
NATIONAL COUNCIL OF JEWISH WOMEN, CHAIR OF COMMITTEES