Martin Zaiac Application PackageZaiac Martin NNAME:
Last Name First Name Middle Initial
4308 Alton Road, Suite 750 Miami BeachHOME ADDRESS:
Apt No.Home No./Street City
FL 33140
State Zip Code
3055884869 3055324478PHONE:
Home Work
drmartyz@aol.com
Email Address
Miami Beach
Street
4308 Alton Rd, Suite 750
City
FL
State
33140
Zip Code
Address:
Greater Miami Skin & laser Center Position:Business Name:Medical Doctor, Director
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.
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No
No
Middle Beach
No
I was born and raised in Miami Beach, and leave strong ties. I am not a board certified Medical Doctor known in the community,
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 City Clerk’s Office. (Regular Boards of City)
Choice 1:
Choice 2:
Choice 3:
Health Advisory Committee
Health Facilities Authority Board
No2. Present participation in Youth Center activities by your children
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:
ages, and which programs. List below:
if yes, please list the names of your children, their
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
* 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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NoƔHave you ever been convicted of a felony:If yes, please explain in detail:
ƔDo you currently have a violation(s) of City of Miami Beach codes:No If yes, please explain in detail:
ƔDo you currently owe the City of Miami Beach any money:No If yes, please explain in detail:
ƔAre you currently serving on any City Boards or Committees:No If yes, which board?
ƔWhat organizations in the City of Miami Beach do you currently hold membership in?
ƔList all properties owned or have an interest in, which are located within the City of Miami Beach:
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ƔI am now employed by the city of Miami Beach:No Which department?
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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.
MaleGender:
Physically Challenged:No
Other
Race/Ethnic Categories
What is your race? Mark one or more races to indicate what you consider yourself to be.
Other Description:
Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino.Yes
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 Martin Zaiac agreed to the following terms on 10/17/2019 2:27:48 PM
Received in the City Clerk's Office by:
Name of Deputy Clerk
Control No.
Date