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Francilee Hand Application Packagef Y 1 1/ \i V 1 I BEACH BOARD AND COMMITTEE APPLICATION FORM Last Nam First Name Mlddle Initial mplu D itun�,lee Home AddressState Zip Code 5313 City/if ity 0 r o ��' /N L& G�- 3! /= 0 Home Telephone Work Telepho Cellular Telephone Email address 30<-9t7 0 & 3o-5- a Business Name , Occupation Business Address City State Zip Code Professional License (describe): Expires: 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 Cityfor a minimum of six months. � • Resident of Miami Beach for a minimum of six (6) months: Yes Zr No 0 • Demonstrates ownership/interest in a business in Mia ' Beach for a minimum of six months: Yes E:Jr No El • Are you a registered voter in Miami Beach: Yes or No 0 • I am now a resident of: North Beach 0 South Beach ElMiddle Beach • I am�CIC ng for an appointment because I have special abilitjes, knowledge and exnerierlce� Please list below: .Lst..7/...!! n . • Are you presently a registered lobbyist with the City of Miami Beach? Yes E-1 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 Health Advisory Committee Parks and Recreation Facilities Board Art in Public Places Committee Health Facilities Authority Board Personnel Board Audit Committee Hispanic Affairs Committee Planning Board*IZ Board of Adjustment Historic Preservation Board Police Citizens Relations Committee Budget Advisory Committee Housing Authority Production Industry Council Committee on the Homeless Human Rights Committee Sister Cities Program Committee for Quality Education in MB LGBT Advisory Committee Sustainability Committee Convention Center Advisory Board Marine & Waterfront Protection Authority Transportation, Parking, & Bicycle -Pedestrian Facilities Committee Cultural Arts Council Miami Beach CommissionforWomen Visitor and Convention Authority1012 92n: Design Review Board W Normandy Shores Local Government Neighborhood Improvement Youth Commission Disability Access Committee Ad Hoc Anti -Bullying Task Force Miami Beach Hall of Fame Selection Committee Ma or 41 Street Committee I Ad Hoc Small Business Task Force Senior Affairs 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 Page 1 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.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: e 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 0 No 0 If yes, please list below the names of your children, their ages and the programs in which they participate: Child's name: Child's name: a Pnva vn i ovor hoan cnnvictari of a foinnv? Ypc Age: Program: Age: Program: nr Nn IPI If vec nlaaca aYnlain in riatnil- e Do you currently have a violation(s) of City of Miami Beach Code? Yes 0 or NoWIf yes, please explain in detail: e Do you currently owe the City of Miami Beach any money? Yes 0 or No lli�If yes, explain in detail: e Are you currently serving on any City Board or Committee? Yes 0 or No E2'lf yes, which *In what organization(s) irr the City of Miami Beach do�ou currently hold membership? /----rit_, -- L r/..c rV(,_ . _ -fi.,. v �-.I.,, 11,x..., Name pwme�— ,� l W �� —��osition Name ��TT !� �� I ositior e List all properties owned or inwhi h u have an interest within the City of Miami Beach: I �ni E 5313 T 9 R 6.4 n e Are you now employed by the City of Miami Beach? Yes 0 or No EL3' Which department and title? WAY df &-*,U d duon j 2ki e Pursuant to City Code Section 2-25 (b): Do you have a parent 0 , spouse 0, child 0 brother 0 or sister 0 who is employed by the City of Miami Beach? Yes 0 or No to— 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 5mplywith City diversity reporting requirements. Gender: Male " Female IV] Race/Ethnic Categories What is your race? 0scan-American/Black '=' Caucasian/White 0 Asian or Pacific Islander 0 Native-American/American Indian Page 2 of 4 CAUsers\CLERQueR\Desktop\BC APPLICATION.doa 0 Other — Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Lagno/a. U9 No Yes Do you consider yourself Physically Disabled? �No 0 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). 0 Sunshine Law - Florida's Govemment-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open government can be found in Chapter 28�E 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 maybe 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." Received in the Office of the City Clerk by: 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 CAUsers\CLERQueRtDesktop\BC APPLICATION.docx MIAMI BEACH City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33134, 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: 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. 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