Daniel Hertzberg Application PackageID MIAMI BEACH
NAME: Hertzberg
Last Name
HOME ADDRESS: 1420 w 22nd st
Apt No. Home No./Street
PHONE: 305-505-1950 305-341-7447
Home Work
Business Name: Coldwell Banker
Address: 1682 Jefferson avenue
Street
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
Daniel N
First Name Middle Initial
Miami Beach FI 33140
City State Zip Code
Danielnhertzberg@gmail.com
Email Address
Position: Real estate agent
Miami Beach FI
City
33139
State Zip Code
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 minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months Yes
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes
• Are you a registered voter in Miami Beach: Yes
• (Please circle one): I am now a resident of: Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
I have served on the VCA Board for the past three years and was the vice chair for the past year. I have extensive work experie
• Are you presently a registered lobbyist with the City of Miami Beach? 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 Citv Clerk's Office. (Regular Boards of City)
Choice 1: Visitor and Convention Authority
Choice 2: Planning Board
Choice 3: Design Review Board
* 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 Issuance Date
License Number
License Expiration Date
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: No Years of Service:
2. Present participation in Youth Center activities by your children No if yes, please list the names of your children, their
ages, and which programs. List below:
. Have you ever been convicted of a felony: No If yes, please explain in detail:
. Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: No If yes, please explain in detail:
• Are you currently serving on any City Boards or Committees: Yes If yes, which board?
VCA
• What organizations in the City of Miami Beach do you currently hold membership in?
Name
Miami Beach Chamber of Commerce
• 1 am now employed by the city of Miami Beach: No
Title
Board of Governors
Which department?
e List all properties owned or have an interest in, which are located within the City of Miami Beach:
Property
1420 w 22nd st
Gender: none
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 federal equal opportunity reporting requirements.
Race/Ethnic Categories
What is your race? Mark one or more races to indicate what you consider yourself to be. none
Other Description:
Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino. No
Physically Challenged: No
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to, the following:
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 board/committee you have served on for period of one year after leaving office (Miami
Beach Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1).
(re: 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).
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 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."
I Daniel Hertzberg agreed to the following terms on 1/10/2018 1:25:35 AM
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date